QASM ANNUAL REPORT 2020

QASM ANNUAL REPORT 2020

5-year review July 2015 to June 2020

Contact Royal Australasian College of Surgeons Queensland Audit of Surgical Mortality PO Box 7476 East Brisbane Qld 4169 Australia Telephone: 61 7 3249 2971 Facsimile: 61 7 3391 7915 Email: QASM@surgeons.org Website: www.surgeons.org/en/research-audit/ surgical-mortality-audits/regional-audits/qasm The information contained in this Annual Report has been prepared by the Royal Australasian College of Surgeons Queensland Audit of Surgical Mortality Management Committee.

The Queensland Audit of Surgical Mortality was established as a Quality Assurance Committee on 30 October 2007 under section 7 (1) of the Health Services (Quality Improvement) Act 1994 (gazetted 9 November 2007).

The Australian and New Zealand Audit of Surgical Mortality, including the Queensland Audit of Surgical Mortality, also has protection under the Commonwealth Qualified Privilege Scheme under Part VC of the Health Insurance Act 1973 (gazetted 2 May 2017).

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ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

Contents QASM CLINICAL DIRECTOR’S REPORT

4

SHORTENED FORMS IN THIS REPORT

5

ACKNOWLEDGEMENTS

6

1

7 7 7 7 7 7 7 8 8

EXECUTIVE SUMMARY 1.1 Overview 1.2 Hospitals 1.3 Surgeons 1.4 Patients 1.5 Operations conducted 1.6 Aboriginal and Torres Strait Islander patients 1.7 Clinical management issues 1.8 Recommendations

2 INTRODUCTION 2.1 Background

9 9

3 METHODS 3.1 Structure and governance 3.2 Surgical death 3.3 Audit process 3.4 Surgeon assessors 3.5 Obstetrician and gynaecologist assessors 3.6 Data management, storage and analysis 3.7 Statistical analysis

10 10 11 11 13 13 14 14

4

AUDIT PARTICIPATION 4.1 Hospitals 4.2 Surgeon participation 4.3 Obstetrician and gynaecologist participation

15 15 15 16

5

RESULTS: ALL PATIENTS 5.1 Notifications of surgical deaths 5.2 Patient admissions 5.3 Patient length of hospital stay 5.4 Patient transfers 5.5 Patient demographics 5.6 Patients who had operations

17 17 17 18 18 18 21

6

RESULTS: ABORIGINAL AND TORRES STRAIT ISLANDER PATIENTS

31

7

OUTCOMES OF PEER-REVIEW ASSESSMENTS 7.1 Assessor-identified clinical management issues 7.2 Assessor-identified areas of concern 7.3 Assessor-identified adverse events 7.4 Preventable clinical management issues

36 36 37 37 38

8 REFERENCES

40

APPENDIX 1: WHAT SURGEONS REPORT THEY WOULD HAVE DONE DIFFERENTLY

41

APPENDIX 2: DATA TABLES

42

APPENDIX 3: DEFINITIONS

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TABLES Table 1: Hospital type for all reviewed surgical deaths, 2015–2020

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Table 2: Surgical specialties of reviewed QASM and ANZASM cases

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Table 3: Age distribution of QASM and ANZASM patients, 2015–2020

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Table 4: Sex ratio of QASM patients, 2015–2020

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Table 5: Comorbidity status of QASM patients, 2015–2020

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Table 6: Most frequently occurring comorbidities in QASM patients, 2015–2020

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Table 7: Most frequently performed operations, 2015–2020

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Table 8: Surgeon-assessed risk of death for QASM patients who had an operation

23

Table 9: Postoperative complications in QASM patients, 2015–2020

26

Table 10: Areas in which management could be improved, 2015–2020

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Table 11: Unplanned returns to theatre, 2015–2020

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Table 12: Unplanned readmissions for patients who had an operation, 2015–2020

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Table 13: Type of DVT prophylaxis provided to all QASM patients, 2015–2020

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Table 14: Characteristics and clinical outcomes of QASM Aboriginal and Torres Strait Islander and non-Indigenous patients who had operations, 2015–2020

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Table 15: Most frequently occurring comorbidities in QASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients who had operations, 2015–2020

33

Table 16: The distribution of QASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients admitted by surgical specialty and the percentage who had an operation, 2015–2020

34

Table 17: The percentage of QASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients who had operations, 2015–2020

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FIGURES

2

Figure 1: Governance structure of QASM

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Figure 2: QASM audit process

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Figure 3: Reviewed QASM cases at census date, 2015–2020

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Figure 4: Age of QASM patients, 2015–2020

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Figure 5: Delays in QASM surgical diagnoses, 2015–2020

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Figure 6: Surgeon-assessed risk of death for QASM patients who had an operation

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Figure 7: ASA class recorded for QASM patients, 2015–2020

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Figure 8: QASM patients with postoperative complications, 2015–2020

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Figure 9: All QASM patients with unplanned admissions to ICU, 2015–2020

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Figure 10: Operative QASM patients with unplanned admission to ICU, 2015–2020

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Figure 11: Clinical team or facility associated with clinical management issue, 2015–2020

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Figure 12: Percentage of adverse events over time, 2015–2020

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DATA TABLES Appendix data table 1: Status of all QASM cases at time of census, 2015–2020

42

Appendix data table 2: Notifications of surgical deaths in reviewed QASM cases by year, 2015–2020

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Appendix data table 3: Age of QASM patients in 20-year age groups, 2015–2020

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Appendix data table 4: Delays in QASM surgical diagnoses by year, 2015–2020

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Appendix data table 5: ASA class recorded for QASM patients, 2015–2020

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Appendix data table 6: QASM postoperative complications by year, 2015–2020

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Appendix data table 7: All QASM patients with unplanned admission to ICU by year, 2015–2020

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Appendix data table 8: QASM operative patients with unplanned admission to ICU by year, 2015–2020

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Appendix data table 9: Clinical team or facility associated with QASM CMI, 2015–2020

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Appendix data table 10: Percentage of clinical management issues that were adverse events by year, 2015–2020 44 Appendix data table 11: Definitely and probably preventable adverse events associated with QASM CMI, 2015–2020

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3

QASM CLINICAL DIRECTOR’S REPORT The last 5 years of QASM has been a very productive process.

The continued collection and management of mortality data has been our basic exercise, but the processing of this to maintain the learning feedback to all surgeons has continued and improved in many ways.

It is so critical to confirm that 100% of surgeons participate in QASM and all public and private hospitals continue to participate also. This makes for a very powerful dataset from which surgeons’ and systems’ learning can be expected, and the lifelong learning for surgeons is enhanced and improved through many facets of the audit process.

Feedback to all surgeons through peer-reviewed comment and recommendation remains strong. Presentations and publications continue to teach us important lessons. Seminars, webinars and symposia are part of the learning process as well and using ASM data only serves to enhance the learning process for all surgeons.

The findings from this five-year dataset should be considered carefully as there are lessons here that can be learnt.

What about the future learnings? Our focus in the next five years may move into a more complex examination of the data using emerging IT processes we have seen in recent years. Whatever we do the primary aim will always be ‘learning’, and that focus will remain and expand without doubt.

Thank you to all the staff and participants who continue to make QASM what it has become.

Dr John North QASM Clinical Director

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SHORTENED FORMS USED IN THIS REPORT ANZASM

Australian and New Zealand Audit of Surgical Mortality

ASA

American Society of Anesthesiologists

CI

confidence interval

CHASM

Collaborating Hospitals’ Audit of Surgical Mortality

CMI

clinical management issue

DVT

deep vein thrombosis

FLA

first-line assessment

ICU

intensive care unit

IQR

interquartile range

LOS

length of stay

NEC

not elsewhere classified

NTASM

Northern Territory Audit of Surgical Mortality

O&G

Obstetrics and Gynaecology

QASM

Queensland Audit of Surgical Mortality

RACS

Royal Australasian College of Surgeons

RANZCOG

Royal Australian and New Zealand College of Obstetricians and Gynaecologists

RR

risk ratio

SCF

surgical case form

SD

standard deviation

SLA

second-line assessment

TED

thrombo-embolus deterrent

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ACKNOWLEDGEMENTS We thank the following individuals and organisations for their contribution to QASM: the Queensland Government for funding QASM all assessors for completing their assessments the Chair, Dr John North, for his leadership and support the QASM Management Committee for its counsel the QASM staff for managing the process.

QASM MANAGEMENT COMMITTEE MEMBERS

Dr John North, Clinical Director, QASM, Royal Australasian College of Surgeons (RACS) Dr Deborah Bailey, Chair, Qld Regional Committee, RACS Dr Ray Lancashire, Deputy Chair, Qld Regional Committee, RACS Dr Jacinta Powell, Executive Director of Medical Services, Forum Representative Dr John Quinn, Executive Director Surgical Affairs (Australia), RACS Dr Neil Smith, Private Hospitals’ Representative Mr Roger White, Community Representative

DEPARTMENT OF HEALTH REPRESENTATIVE

Ms Kirstine Sketcher-Baker, Executive Director, Patient Safety and Quality Improvement Service

OBSTETRICS AND GYNAECOLOGY REPRESENTATIVE Dr Tal Jacobson, Obstetrics and Gynaecology Representative

QASM STAFF

Dr John North, Clinical Director Jenny Allen, QASM Project Manager Therese Rey-Conde, Senior Research Officer Sonya Faint, Senior Project Officer Candice Postin, Senior Project Officer Kyrsty Webb, Administration Officer

ANZASM STAFF

Professor Guy Maddern, Chair ANZASM Steering Committee A/Professor Wendy Babidge, General Manager, Research Audit and Academic Surgery Dr Helena Kopunic, Manager, Surgical Audit, Research Audit and Academic Surgery Dr Lettie Pule, Research Officer, Surgical Audit, Research Audit and Academic Surgery

STATISTICIAN

Prof Robert Ware, School of Medicine, Griffith University

DATA ANALYST

Dr Ryan Maloney, RACS

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EXECUTIVE SUMMARY

1.1 Overview

T he Queensland Audit of Surgical Mortality (QASM) is an external, independent, peer-review audit of care processes associated with surgical deaths in Queensland.

A surgical death is one in which a surgeon was responsible for, or had significant involvement in, the patient’s care regardless of whether the patient had an operation.

T he purpose of QASM is to inform, educate, facilitate change, and improve practice by providing feedback. Surgeons are encouraged to use QASM feedback and self-reflection to improve their practice. Hospitals and policy makers are encouraged to use feedback to develop strategies to address clinical management areas in need of improvement and staffing gaps in the surgical workforce.

Q ASM has Qualified Privilege protection under Commonwealth legislation.

T his report covers the period 1 July 2015 to 30 June 2020.

1.2 Hospitals

A ll public and private hospitals in Queensland participate in QASM.

1.3 Surgeons

A ll practising surgeons in Queensland participate in QASM as part of their continuing professional development requirement.

L ocum surgeons are encouraged to participate in QASM. 6 7.4% (3,790/5,620) of the operations were performed by consultant surgeons.

1.4 Patients

F rom July 2015 to June 2020, patients were included in QASM if they died under the care of a surgeon. Of those patients; 57.3% (2,959/5,163) were male and 42.7% (2,204/5,163) were female; 80.4% (4,151/5,163) were between 60 and 99 years of age.

F rom July 2015 to June 2020, over 5,000 patient cases (n=5163) were reviewed, and feedback sent to the treating surgeon by the census date of 1 October 2020. These are the basis of this report.

F rom July 2015 to June 2020, 89.3% (4,598/5,149) of patients in QASM had at least one comorbidity. This is similar to currently available national ANZASM data (2009–2016), where 90.1% (28,701/31,862) of surgical patients who died had comorbidities.[1] C ardiovascular disease was the most frequently documented comorbidity and was present in 66.6% of patients (3,043/4,598).

1.5

Operations conducted

7 8.9% (4,070/5,163) of patients had an operation.

7 6.1% (3,175/4,070) of patients had one operation.

6 .7% (345/5,140) of patients had a delay in surgical diagnosis. Delays in surgical diagnosis decreased from 7.4% (82/345) in 2015–2016 to 5. 3% 941/345) in 2019–2002.

1 5.0% (608/4,053) of patients who had an operation had an unplanned return to theatre. There was no statistical change in unplanned returns to theatre during the reporting period.

2 .8% (111/4,027) of patients who had an operation had a readmission. There was no statistical change in readmissions during the reporting period.

1.6

Aboriginal and Torres Strait Islander patients

F rom July 2015 to June 2020, 148 patients identified as Aboriginal and Torres Strait Islander (2.9%; 148/5,163).

A boriginal and Torres Strait Islander Aboriginal and Torres Strait Islander patients were 19 years younger than nonIndigenous patients (median age 58 vs 76 years).

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A boriginal and Torres Strait Islander patients were more likely to be transferred (42.6% 52/122) than non-Indigenous patients (27.0%; 1,049/3,879).

A boriginal and Torres Strait Islander patients were twice as likely to have 3 or more comorbidities per patient 68.2%; 73/107) than non-indigenous patients 36.7%; 1,283/3,494).

A boriginal and Torres Strait Islander patients were less likely to have an operation (83.0%; 122/147) than nonIndigenous patients (96.9%; 3,948/5,011).

F ewer Aboriginal and Torres Strait Islander patients were admitted under orthopaedic surgeons (8.8%; 13/148) than were non-Indigenous patients (20.2%; 1,013/5,015) although the same percentage of patients had orthopaedic operations ([Aboriginal and Torres Strait Islander 84.6%; 11/13] vs [non-Indigenous 84.1%; 1,013/1,294]).

A ll Aboriginal and Torres Strait Islander patients admitted under vascular and paediatric surgeons had an operation.

A boriginal and Torres Strait Islander patients who had operations were nearly twice as likely to die following Vascular and Cardiothoracic Surgery and four times as likely to die following a paediatric operation than were non-Indigenous patients (vascular – 18.0% [22/122] vs 10.1% [399/3,948]; cardiothoracic – 18.9% [23/122] vs 10% [396/3,948]; paediatric – 4.9% [6/122] vs 0.9% [44/3,948]).

1.7

Clinical management issues

A ssessors identified no clinical management issues (CMIs) in almost 80.0% of patient’s deaths (80.7%; 4,076/5,050).

A ssessors identified CMIs in 974 patients (19.3%; 974/5,050), who had a combined total of 1,002 CMIs. A ssessors determined that 64.3% (644/1,002 of the CMIs) were areas of consideration (the least serious level of concern), 25.5% (256/1,002 were areas of concern) and 10.2% (102/1,002) were adverse events — the most serious level of concern.

A ssessors identified a decrease in the number of adverse events from 2.6% (26/1,002) in 2015 to 1.2% (12/1,002) in 2020. Assessors considered that 57.4% (542/945) of CMIs were definitely or probably preventable. These occurred more in postoperative situations (17.0%; 92/542) than preoperative (14.8%; 80/542); or intraoperative situations (7.4%; 40/542).

T he most frequent preventable CMI was ‘the decision to operate’ (10.9%, 59/542).

O ne-quarter of obstetrics and gynaecology (O&G) cases reported to QASM had a CMI (25.8%; 8/31). The low number of reported cases could affect the percentage of cases for which a CMI was identified.

1.8 Recommendations

Recommendations based on QASM data for improvements in surgical care in Queensland: Q ASM to share the Aboriginal and Torres Strait Islander patient information with Queensland Health’s Aboriginal and Torres Strait Islander Health Division. The Aboriginal and Torres Strait Islander Health Division is to review and consider opportunities for action in light of QASM’s report showing that Aboriginal and Torres Strait Islander patients have an increased need for transfer (Table 14 ). Earlier diagnosis and treatment at primary care level could reduce the need for transfers.

Q ASM to notify Queensland surgeons of the particular surgical services needs of Aboriginal and Torres Strait Islander patients (Table 17) and alert them to the additional surgical competency report implemented by RACS (Cultural competency and cultural safety). RACS must monitor that this competency is fulfilled for professional development.

Q ueensland surgeons to actively involve consultant geriatricians and seek consultant geriatrician input in the surgical management of all patients 60 years or older (80.7% of QASM patients) (Table 3).

T he Royal Australian and New Zealand College of Obstetricians and Gynaecologists and QASM to identify and determine suitable actions to reduce CMIs. Despite the low number of O&G cases reported, QASM assessors identified a high percentage of CMIs in those cases (Section 4.3).

Q ueensland surgeons to pay more attention to fluid balance issues and request appropriate consultation, particularly for elderly patients. QASM to discuss with the Queensland Surgical Advisory Committee strategies to improve fluid balance management with approximately 10.0% of QASM patients reported as having fluid balance issues (Table 14).

Q ueensland surgeons to consider aspiration risks in their patients. Surgeons should identify early and monitor closely patients at risk of developing aspiration pneumonia pneumonia—a recognised contributor to the deaths of some patients and the most frequent preventable adverse event (12.5%; 4/32) (Section 7.2). QASM is producing a how-to document to minimise aspiration pneumonia risks in consultation with the Queensland Surgical Advisory Committee.

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2 INTRODUCTION 2.1 Background

Surgery in Queensland is safe and well-regulated. Only a small percentage of surgical patients die. When a death does occur, it is reviewed by the consultant surgeon and by the surgeon’s peers. The Royal Australasian College of Surgeons (RACS) is responsible for facilitating this review process through the Queensland Audit of Surgical Mortality (QASM), an external independent peer-review audit of processes of care associated with surgery-related deaths in Queensland.

The first QASM peer-reviewed assessment was conducted in 2007.

QASM is designed as a feedback mechanism for participating surgeons to encourage reflection on surgical care and practice following the death of a patient. Information submitted to QASM by the consultant surgeon provides an opportunity to identify areas in which care could be improved. Surgical peers review and assess the clinical management of each patient (including hospital systems and processes) and provide feedback for the consultant surgeon. The deidentified, aggregated results of these reviews are presented in this document. (Note: Consultant surgeons are referred to as surgeons in this report).

QASM provides feedback as follows: S urgeons receive written feedback from assessors on each of their cases.

S urgeons receive an electronic copy of the QASM Annual Report, which is also available on the RACS website.

S urgeons receive deidentified summaries of assessments in the National Case Note Review Booklet, which details a selection of deidentified patient cases across Australia.

H ospitals participating in the audit receive clinical governance reports of aggregated deidentified data. These reports allow each hospital to compare their hospital with others across Australia.

S urgeons can access online reports relating to their own audit data via the QASM website.

Each self-assessment and peer-review assessment in the QASM database provides valuable insights into current practice and shows opportunities for practice improvement. Ongoing refinements to QASM audit processes enhance the quality and reliability of data captured by QASM over time.

This report covers surgical deaths that occurred from 1 July 2015 to 30 June 2020 (census date 1 October 2020).

Data analysis relates to the date of death rather than the notification date to QASM. The nature of the audit process means that some patient cases reported during this period will still be undergoing review as of the census date and will be included in the next QASM report. Please note that denominators in this report sometimes differ because not all surgical case form (SCF) questions were answered for each patient.

The objectives of QASM are to: e ncourage and support surgeons to self-appraise their clinical care management e ncourage and support surgeons to appraise the clinical care management of their peers i nform, educate, facilitate change and improve practice by providing feedback on surgical deaths in Queensland.

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3 METHODS 3.1

Structure and governance

The governance structure of QASM is illustrated in Figure 1 Figure 1: Governance structure of QASM

Qld Minister of Health

RACS Council

Qld Department of Health

RACS Professional Standards and Advocacy Committee (PSAC)

Qld public hospitals

Surgical Audit Committee (SAC)

Qld private hospitals

Australian and New Zealand Audit of Surgical Mortality Steering Committee

Qld consultant surgeons

QASM Management Committee

QASM project staff

Note: RACS: Royal Australasian College of Surgeons; QASM: Queensland Audit of Surgical Mortality; QLD: Queensland

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3.2

Surgical death

QASM defines a surgical death as the death of a patient under the care of a surgeon, even if the patient did not have an operation.

The audit includes all surgical deaths that meet one or more of the following criteria: T he patient was under the care of a surgeon (surgical admission) and may or may not have received an operation.

T he patient was under the care of a physician (medical admission) and subsequently underwent a surgical procedure.

T he patient’s death was possibly or definitely related to anaesthesia during surgery or occurred within 48 hours of surgery.

T he patient was a gynaecology-related case.

The audit excludes all surgical deaths where the patient was deemed terminal upon admission and did not have an operation.

3.3

Audit process

The audit process begins when a surgical or medical records department in a Queensland hospital notifies QASM of a surgical death, or when a surgeon self-reports a surgical death. The process combines surgeon self-reflection with peer review of all surgical deaths in Queensland to determine whether the death was a direct result of the disease process alone, or if aspects of patient management or hospital systems and processes may have contributed.

Anaesthetists, obstetricians and gynaecologists may also participate in cases related to their specialties.

The overall audit process is coordinated by QASM staff and is outlined in Figure 2.

Appendix 3 provide definitions of all terms used in the audit process.

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Figure 2: QASM audit process QASM receives notification of surgical death

SCF sent to surgeon for online completion or surgeon initiates process by self-reporting the surgical death

SCF completed online and returned to QASM

SCF is sent for first-line assessment (deidentified) Anaesthetic case form (if relevant) is also sent for FLA

Yes Clinical Director selects second assessor

No

Is an SLA required?

Feedback to surgeon SLA Reviewed case closed Feedback to surgeon

Has an appeal been lodged against the SLA?

No

Reviewed case closed

Yes Clinical Director selects additional second-line assessor

Additional SLA

Feedback to surgeon

Reviewed case closed

QASM = Queensland Audit of Surgical Mortality; SCF = surgical case form; FLA = first-line assessment; SLA = second-line assessment

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3.4

Surgeon assessors

Surgeons participate in QASM in the following capacities: a s a surgeon who self-assesses the clinical management provided to the patient under review a s a peer assessor who conducts a first-line assessment (FLA) or second-line assessment (SLA). First- and secondline assessors are surgical peers, sometimes from a different Australian state or territory (to Queensland) to preserve anonymity and facilitate impartiality.

Surgeons and peer assessors (first- or second-line) review patient cases to identify any clinical management issues (CMIs), including hospital systems and processes, where care could have been better. Patients may have more than one CMI reported. This QASM report includes only one CMI per patient—that reported by the highest-level assessor (i.e. the second-line assessor if an SLA is performed, otherwise the first-line assessor).

Surgeons and assessors provide a clinical judgement on one of the two possible outcomes: 1. The patient’s death was a direct outcome of the disease process and clinical management had no impact on the outcome.

2. Aspects of clinical management may have contributed to the death of the patient.

If the latter, surgeons and assessors may identify CMIs that are classified as: A rea of consideration: the assessor believes an area of care could have been improved or different but recognises that there may be debate about this.

A rea of concern: the assessor believes that an area of care should have been better.

A dverse event: the assessor identifies an unintended injury caused by medical management, rather than by the disease process, which is sufficiently serious to either: lead to prolonged hospitalisation lead to temporary or permanent impairment or disability of the patient at the time of discharge contribute to, or cause, death.

Surgeons and assessors are asked to: r eport the impact of the CMIs on the outcome, using the following categories:

 made no difference to the death  may have contributed to the death  c aused the death of a patient who would otherwise have been expected to survive.

g ive their opinion of whether the CMI was preventable, using the following categories:

 definitely  probably  probably not  definitely not preventable

i ndicate who the CMI was associated with, using the following categories:

 audited surgical team  another clinical team  hospital

3.5

Obstetrician and gynaecologist assessors

Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) began participating in QASM in 2012. Obstetricians and gynaecologists voluntarily participate in the audit as first- or second-line assessors if the patient was a gynaecology-related case. The assessment process for obstetricians and gynaecologists is the same as for surgeons. Most of these reviews were of gynaecological cases.

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3.6

Data management, storage and analysis

3.7

Statistical analysis

All data reported from QASM are deidentified to preserve the confidentiality of the patient, surgeon and hospital.

Data are encrypted and stored in a bespoke database. Transactions are time stamped and all changes to audit data are written to an archive table to provide a complete audit trail of each patient case. The database has an integrated workflow rules engine that enables QASM staff to generate letters, reminders and management reports. QASM staff routinely cross-check all data against the original SCF, and the FLA and SLA forms. Data are cleaned using logic testing and manually reviewed before analysis.

Statistical analysis is performed using IBM SPSS Statistics (version 24.0). Graphs have been produced with Microsoft Office Excel (2010).

The total number of patients used in each analysis varies because not all data points in the original SCF were completed.

Continuous variables are summarised using medians and the interquartile range (IQR), which shows the values within the 25% and 75% percentiles of the data. Reporting the IQR overcomes the problems that arise when reporting the range, as extreme values do not influence the summary statistics.

Risk ratios (RRs) are calculated for variables that have a dichotomous outcome to assess the risk of an event in one group versus the risk of the event in the reference group. All RRs are reported with a 95% confidence interval (CI). RRs are interpreted as follows: RR > 1: if the patient has the characteristic of interest, they have an increased risk of that outcome than does the reference group.

RR ≈ 1: no difference or little difference in risk (incidence in each group is the same).

RR < 1: if the patient has the characteristic of interest, they have a reduced risk than does the reference group.

Qualitative responses are analysed by QASM staff and classified into themes.

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4

AUDIT PARTICIPATION

4.1 Hospitals

All public and private hospitals certified to provide surgical services in Queensland participate in QASM. These hospitals notified QASM of 6,685 patient surgical deaths by the 2020 census date (1 October 2020). The QASM review process was completed for 5,163 patients, which are the basis of this report.

The distribution of hospitals where surgical deaths occurred can be roughly divided into three-quarters from public hospitals and one-quarter from the private sector, with a small fraction from co-located hospitals (Table 1). In general, in Queensland many more interventions occur for acute overnight separations in the public sector than in the private sector.[2] (A separation is a completed episode of care for an admitted patient [Appendix 3: Definitions]).[3] Table 1: Hospital type for all reviewed surgical deaths, 2015–2020 (n=5,163) Hospital type

QASM patients

% of total deaths

Public

3,993

77.3

Private

1,113

22.0

Co-located

34

0.7

*Data missing for n=1,119 patients (16.7%).

4.2

Surgeon participation

Queensland surgeons participate in QASM as surgeons (responsible for the patient case under review), peer surgeons (those who provide FLAs or SLAs), locums or Specialist International Medical Graduates.

A total of 1,359 surgeons participated in QASM from 2015–2020, including 331 consultant specialists in obstetrics and gynaecology. Surgeons from 14 surgical specialties completed SCFs for QASM (Table 2).

Table 2: Surgical specialties of reviewed QASM and ANZASM cases Reviewed QASM cases (n=5,163) 2015-2020

Surgical specialty

Reviewed ANZASM cases* (n=11,916) 2015-2020

n

(%)

n

(%)

General

1,874

36.3

4,439

37.3

Orthopaedic

1,217

23.6

2,260

18.9

Neurosurgery

718

13.9

1,737

14.6

Vascular

475

9.2

1,031

8.7

Cardiothoracic

442

8.6

1,271

10.6

Urology

232

4.5

549

4.6

Otolaryngology Head and Neck

61

1.2

136

1.2

Paediatric

51

1.0

92

<1.0

Plastic and Reconstructive

48

<1.0

354

3.0

O&G

29

<1.0

29

<1.0

Ophthalmology

7

<1.0

12

<1.0

Oral/maxillofacial

4

<1.0

6

<1.0

O&G = Obstetrics and Gynaecology *ANZASM data excludes Qld (QASM) and NSW (CHASM) data but covers all other states and territories.

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In QASM, there were fewer Cardiothoracic and Plastic Surgery patients, and more Orthopaedic Surgery patients, than in ANZASM (Table 2). This cannot be explained by age differences in the 2 populations because the age ranges are similar (Table 3).

4.2.1 Surgical case forms Most SCFs were completed by the census date (97.3%; 6,243/6,418), with only 175 still in progress (2.7%). (QASM is an ongoing process so some cases were under assessment at the time of reporting. Only surgical deaths that have completed the audit review process and have a status of ‘reviewed’ were included in the analysis for this report. Cases under assessment will be included in the next reporting period.). Appendix table 1 contains the status of all surgical deaths monitored by QASM at the time of census (1 October 2020).

4.2.2 Surgeon views in retrospect Within the SCF, surgeons are asked to consider whether—in retrospect—they would have done anything differently in terms of patient management. (This question was unanswered for 130 patients [2.5%; 130/5,163].)

For 86.7% (4,364/5,033) of patients, the surgeon would not have changed the patient’s management.

For 13.3% (669/5,033) of patients, the surgeon would have done something differently.

The areas of care identified by surgeons for improvement covered all aspects of patient management. A sample of comments is provided in Appendix 1.

4.3

Obstetrician and gynaecologist participation

FLAs occurred for 31 O&G cases (7 cases progressed to SLA). CMIs were identified in 25.8% (8/31) of O&G cases.

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5

RESULTS: ALL PATIENTS

5.1

Notifications of surgical deaths

QASM had been notified of 6,685 patient surgical deaths by the 1 October 2020 census date. The QASM review process was completed for 5,163 patients, which forms the basis of this report (Figure 3).

Figure 3: Reviewed QASM cases at census date, 2015–2020 (n=5,163) 1200

Closed cases (n)

1000

800

600

400

200

0 2015–16

2016–17

2017–18

2018–19

2019–20

Year Reference: Appendix data table 1; Appendix data table 2

Surgeons completed 5,163 FLAs and 756 SLAs during 2015–2020. Most cases were closed after FLA (85.4%; 4,407/5,163). The percentage of cases sent to second-line assessors was 14.6% (756/5,163). In 2015–2020, 11.7% of SCFs (605/5,163) contained insufficient information for the first-line assessor to report on the case; these progressed to SLA. Hospitals are notified of the number of cases allocated for SLA due to insufficient information.

A sample of first-line assessors’ comments in 2015–2020:

The case information is extremely lacking. There is one sentence regarding the clinical course of this patient.

The text was impossible to read.

T he only information given was that the patient was a male and in hospital for 6 days. There is no information with regards to symptoms; signs or management leading up to death.

5.2

Patient admissions

Most patients were emergency admissions (86.7%; 4,453/5,138). Only a small percentage were elective admissions (13.3%; 685/5,138), and 25 cases (0.5%) had no admission status recorded.

A similar percentage of emergency admissions versus elective admissions was observed nationally during 2015– 2020. The ANZASM data shows that 84.8% of cases were emergency admissions (10,103/11,917), with 15.2% being elective cases (1,814/11,917). These percentages exclude the 842 cases with no admission status recorded (7.0%; 842/11,917).

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17

5.3

Patient length of hospital stay

5.4

Patient transfers

5.5

Patient demographics

The median length of stay (LOS) in hospital for the episode in which the death occurred was 10 days (IQR 4–20 days).

Not all patients had an operation. LOS was longer for patient with an operation than without. Patients who had an operation had a median LOS of 12 days (IQR 5–23 days), compared with 4 days (IQR 2–10 days) for patients who did not have an operation.

Queensland is a large, decentralised state, leading to wide variation in the distance patients need to be transferred from one hospital to another. Of QASM patients, 28.5% (1,439/5,049) had been transferred between hospitals.

Transfer distances ranged from less than 1 km to 10,000 km (3 patients transferred from international or offshore locations). The mean distance transferred was 204 km (standard deviation [SD] 472) and the median distance was 80 km (IQR 25–250).

5.5.1 Patient age Overall, patients included in QASM and ANZASM are elderly patients and their ages are similar between the audits.

Half of QASM patients were age 65 to 85 years with a median age of 76 years (IQR 65–85), similar to the median age of ANZASM patients (77 years; IQR 65–86). The most frequently occurring age (mode) across the 5-year QASM reporting period was 82 years (Table 3).

Table 3: Age distribution of QASM and ANZASM patients, 2015–2020.

Age statistics

Ages of QASM patients (n=5,163)

Age of ANZASM patients* (n=11,917)

Mean ±SD

72 (19)

72 (18)

Median (IQR)

76 (65–85)

77 (65–86)

Mode

82

83

Minimum

0

0

Maximum

102

105

Source: Notification of death form *ANZASM data excludes Qld (QASM) and NSW (CHASM) data but covers all other states and territories.

QASM patients ranged in age from very young to very old—56 patients were younger than one year (1.1%; 56/5,163) and 14 patients (0.3%; 14/5,163) were 100 years or older. Most patients (80.4%; 4,151/5,163) were between 60 and 99 years of age (Figure 4).

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ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

Figure 4: Age of QASM patients, 2015–2020 (n=5,163)

45.0 40.0 35.0

Patients (%)

30.0 25.0 20.0 15.0 10.0 5.0 0.0 0–19

20–39

40–59

60–79

80–99

100+

Age group in years Reference: Appendix data table 3

5.5.1.1 QASM patients 80–99 years The most common operations for patients 80–99 years were: exploratory laparotomy (n=139) primary open reduction and internal fixation femoral break (n=138) prosthetic cemented hemiarthroplasty of hip (n= 110) freeing adhesions of peritoneum (n=69) debridement of skin (n=50).

5.5.1.2 QASM patients 100 years or older Patients who were 100 years or older mostly required Orthopaedic, General or Vascular Surgery. In this age group, 27 operations were performed on 20 patients. The most common operations were: fixation of fractured neck of femur (n=5) exploratory laparotomy (n=1) freeing adhesions of peritoneum (n=1).

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5.5.2 Patient sex More males than females died during surgical admissions in Queensland hospitals, both in the five-year reporting period of 2015–2020 and the most recent reporting period of 2019–2020.

Table 4: Sex ratio of QASM patients, 2015–2020 (n=5,163) Year

Male Patients (n)

Female % of total

Patients (n)

% of total

2015–2016 (n=1,121)

610

54.4

511

45.6

2016–2017 (n=1,084)

587

54.2

497

45.8

2017–2018 (n=1,104)

642

58.2

462

41.8

2018–2019 (n=1,077)

642

59.6

435

40.4

2019–2020 (n=777)

478

61.5

299

38.5

Total (n=51,63)

2,959

57.3

2,204

42.7

Source: Notification of death form

The QASM percentages compare well with the national data, where males were 57.1% of the total and females were 42.9% of the total. In QASM there has been an increase in the number of males over the last few years.

5.5.3 Patients with comorbidities Surgeons recorded all known comorbidities (coexisting medical conditions that are a threat to life). Nearly all patients had at least one comorbidity (89.3%; 4,598/5,149) (Table 5). The median number of comorbidities was 3 (IQR 2–4), with a minimum of 1 and a maximum of 10.

Table 5: Comorbidity status of QASM patients, 2015–2020 (n=5,149*) Comorbidity status

Patients (n)

% of total

Comorbidities present

4,598

89.3

No comorbidities present

551

10.7

*Missing data n=14 patients (0.3%) Source: Surgical case form

Of the patients with comorbidities, only 15.0% had one comorbidity (685/4,568) and 85.0% (3,883/4,568) had multiple comorbidities. Cardiovascular disease 66.5%) was the most frequently reported comorbidity (Table 6).

Table 6: Most frequently occurring comorbidities in QASM patients, 2015–2020 (n=4,568*) Comorbidity

Patients (n)

% of total

Cardiovascular disease

3,039

66.5

Respiratory

1,639

35.9

Renal

1,375

30.1

Other

1,224

26.8

Neurological

1,009

22.1

Diabetes

987

21.6

Advanced malignancy

911

19.9

Obesity

539

11.8

Hepatic

383

8.4

Patients often have more than one comorbidity. Total 11,105 comorbidities reported for 4,568 patients. *Missing data n=30 patients (0.7%) Source: Surgical case form

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ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

5.6

Patients who had operations

In this report, the term operation refers to both operations and procedures (i.e. an operation may refer to a relevant radiological or endoscopic procedure).

Most QASM patients admitted under the care of a surgeon had a surgical operation (78.9%; 4,070/5,158). Although this is a surgical audit, 21.1% (1,088/5,158) of patients did not have an operation (data missing n=5 of 5,163 patients [0.1%]).

Surgeons performed a total of 5,620 operations; consultant surgeons performed 67.4% (3,790/5,620) of these operations. More than half of the operations were the only operation for that patient (56.5%; 3,175/5,620).

The most frequently performed operations across 2015–2020, representing 46.6% (2,620/5,620) of all operations, are presented in Table 7.

Table 7: Most frequently performed operations, 2015–2020 (n=5,620) Operation type

Patients (n)

% of total operations

Exploratory laparotomy

465

8.3

Prosthetic cemented hemiarthroplasty of hip

409

7.3

Reopening of laparotomy site

273

4.9

Debridement of skin

249

4.4

Burr hole(s) for ventricular external drainage

181

3.2

Lavage of peritoneum

172

3.1

Freeing of adhesions of peritoneum

146

2.6

Debridement of muscle

91

1.6

Laparotomy approach

80

1.4

Irrigation of peritoneal cavity

72

1.3

Right hemicolectomy and anastomosis NEC

70

1.2

Removal of shunt ± insertion of external drain

66

1.2

Replacement of aneurysmal bifurcation of aorta

63

1.1

Diagnostic gastroscopy

61

1.1

Open irrigation joint

57

1.0

Amputation above knee

57

1.0

Creation of ileostomy

54

1.0

Endoscopic insertion of ureteric stent

54

1.0

NEC = not elsewhere classified Source: Surgical case form

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5.6.1 Patients with delays in surgical diagnoses Delays in surgical diagnoses are associated with higher mortality rates in surgical patients.[4] The percentage of QASM patients with delay recorded varies slightly across years, with 2019–2020 being a better year than most. Delay in surgical diagnosis decreased from 7.4% in 2015-2016 to 5.3% in 2019-2020 (Figure 5).

Across 2015–2020, 345 patients had a delayed surgical diagnosis (6.7%; 345/5,140). The causes of the delays were mostly associated with medical departments (31.6%; 109/345), surgical departments (26.4%; 91/345) and with general practitioners (GPs) (37.7%; 23/345). Some surgeons reported delays in diagnoses for a few patients but gave no further details.

The 5 most frequently reported causes of delay were: unavoidable causes (n=98) inexperienced staff (n=75) misinterpretation of results (n=70) Incorrect test requested (n=36) results not seen (n=7).

Cases with delays in surgical diagnosis (%)

Figure 5: Delays in QASM surgical diagnoses, 2015–2020 (n=345) 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 2015–16

2016–17

2017–18

2018–19

2019–20

Year Reference: Appendix data table 4

100 90

22

Admissions (%)

80 70 60 50 40 30 20

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

5.6.2 Patient preoperative risk of death Surgeons assessed each patient’s risk of death prior to surgery (reported for 99.0% [4,028/4,070] of patients who had an operation). Risk of death, while subjective, reflects the complexity of the procedure in the context of the patient’s presentation, estimated physiological reserve and American Society of Anesthesiologists (ASA) status. Surgeons assessed 75.7% of patients (3,048/4,028) as having a moderate or considerable risk of death prior to surgery.

Death was expected for 12.5% of patients (504/4,028) who underwent at least one operation (Table 8 and Figure 6). Over time, the surgeon’s assessment of risk of death for the most complex patients (moderate, considerable or expected) was not statically different (x2 = 8.71, p = 0.37).

Table 8: Surgeon-assessed risk of death for QASM patients who had an operation (n=4,028*) Patients, n (%) Risk of death

2015–2016

2016–2017

2017–2018

2018–2019

2019–2020

(n)

(n)

(n)

(n)

(n)

(%)

(%)

(%)

(%)

Total

(%)

(n)

(%)

Minimal

22

2.5

13

1.6

24

2.8

20

2.3

26

4.3

105

2.6

Small

86

9.8

76

9.1

71

8.2

74

8.7

64

10.6

371

9.2

Moderate

224

25.5

234

28.1

218

25.3

203

23.8

133

22.1

1,012

25.1

Considerable

439

49.9

411

49.3

429

49.8

444

52.1

313

52.0

2,036

50.5

Expected

109

12.4

99

11.9

119

13.8

111

13.0

66

11.0

504

12.5

Source: Surgical case form *Missing data n=42 patients (1.0%)

Figure 6: Surgeon-assessed risk of death for QASM patients who had an operation (n=4,028*)

Estimated risk of death before operation 2015-2020 60% 50%

2000

40%

1500

30% 1000

20%

500

Proportion of patients

Number of patients

2500

10%

0

0% Minimal

Small

Moderate

Considerable

Expected

Risk of death Source: Surgical case form *Missing data n=42 patients (1.0%)

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5.6.3 American Society of Anesthesiologists (ASA) class Anaesthetists use the American Society of Anesthesiologists (ASA) physical status classification system to assess a patient’s preoperative risk, based on the patient’s comorbidities and other factors.[5] The classification levels range from ASA class 1 (normal, healthy patient) to ASA class 6 (declared brain-dead patient). QASM surgeons record ASA class for all patients regardless of whether they receive an operation or not.

The median ASA class was 4 (IQR 3–4), and 61.1% (2,781/4,555) of patients had an ASA class of at least 4. Patients with an ASA class 4 have severe systemic disease that is a constant threat to life (Figure 7).

Figure 7: ASA class recorded for QASM patients, 2015–2020 (n=4,555*) 50.0 45.0

Patients with ASA class (%)

40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 1

2

3

4

5

6

ASA class ASA class 1 = a normal healthy patient; ASA class 2 = a patient with mild systemic disease; ASA class 3 = a patient with moderate systemic disease; ASA class 4 = a patient with severe systemic disease that is a constant threat to life; ASA class 5 = a moribund patient unlikely to survive 24 hours, who is not expected to survive without an operation; ASA class 6 = a patient declared brain dead whose organs are being removed for donor purposes. *Missing data n=608 patients (11.9%) Reference: Appendix data table 5.

100

Patients transferred (%)

90 80 70 60 50 40 30 20 10 0

24

2010–11

2011–12

2012–13

2013–14

2014–15

2015–16

Year

2016–17

2017–18

2018–19

2019–20

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

5.6.4 Patients with postoperative complications Postoperative complications occurred in 31.7% of patients (1,277/4,028) during 2015–2020. The frequency of postoperative complications is decreasing over time, from 35.0% of all operations in 2015–2016 to 27.2% of all operations in 2019–2020 (Figure 8).

There was a delay in recognising postoperative complications in 5.0% (62/1,238) of cases that had them (data missing n=39 of 1,277 [3.2%]).

Patients with postoperative complications (%)

Figure 8: QASM patients with postoperative complications, 2015–2020 (n=1,277) 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 2015–16

2016–17

2017–18

2018–19

2019–20

Year Reference: Appendix data table 6

Of the patients with complications, the most frequently recorded complications were: tissue ischaemia: 12.4% (153/1,238) significant postoperative bleeding: 12.4% (154/1,238) procedure-related sepsis: 10.7% (132/1,238) anastomotic leaks: 9.9% (123/1,238).

Of the patients who had operations, the most frequently occurring postoperative complication group was infection 160 (procedure-related sepsis, 3.2%; 155/4,028 and sepsis 0.8%; 23/4,028 ). Postoperative complications are listed by frequency 140in Table 9. Some of the patients who died had several complications.

120 100 80 60 40 20 0 0–10

11–20

21–30

31–40

41–50

51–60

61–70

71–90

81–90

91+

Age groups in years

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Table 9: Postoperative complications in QASM patients, 2015–2020 (n=4,028*) Postoperative complication

Patients (n)

Per cent of patients with complications (%)

Tissue ischaemia

153

3.8

Significant postoperative bleeding

154

3.8

Procedure-related sepsis

132

3.2

Anastomotic leaks

118

2.9

Aspiration pneumonia

70

1.7

Cardiac complications

43

1.1

Cerebral events

33

0.8

Pneumonia

30

0.7

Pulmonary embolus

30

0.7

Multiple organ failure

28

0.7

Respiratory failure

24

0.6

Sepsis

23

0.6

Renal failure

20

0.5

Stroke

14

0.3

Wound complication

14

0.3

Ileus

13

0.3

Kidney injury

11

0.3

Small bowel complication

12

0.3

Pulmonary embolus

7

0.2

Source: Surgical case form *Missing data n=42 patients (1.0%)

Surgeons identified fewer problems with postoperative than preoperative care, although this difference was not reflected in peer-reviewed assessments (Table 10).

Surgeons felt that 4.4% (177/4,030) of cases should have had better postoperative care (data missing n=40/4,070 [1.0%]). However, first- and second-line assessors were more likely (6.1% [235/3,871]) than the treating surgeons to consider that the patient should have had better postoperative care: RR 1.4 (95% CI 1.1 to 1.7). The same is true for preoperative care, the choice of operation and intraoperative management. This is despite fewer assessors answering all of the management questions (n-117/4070 [4.3%]).

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ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

Table 10: Areas in which management could be improved, 2015–2020 (n=4,047) Surgeons

Assessors

Patients (n)

% of patients

Patients (n)

% of patients

Risk ratio** (95% CI)

Preoperative care

291/4,046

7.2%

345/3,893

8.9%

1.2 (1.1–1.4)*

Decision to operate

299/4,043

7.4%

312/3,908

8.0%

1.1 (0.9–1.3)

Choice of operation

78/4,047

1.9%

171/3,901

4.4%

2.3 (1.7–3.0)*

Timing of operation

224/4,044

5.5%

236/3,889

6.1%

1.0 (0.8–1.2)

Intraoperative management

98/4,040

2.4%

153/3,867

4.0%

1.6 (1.3–2.1)*

Postoperative care

177/4,030

4.4%

235/3,871

6.1%

1.4 (1.1–1.7)*

Note: not all surgeons or assessors answered all the questions. Fewer assessors than surgeons answered all the questions. *Statistically significant but may not be clinically significant. ** Risk ratios are at 95% confidence interval. Risk ratio is the cumulative incidence or risk of disease in one group divided by the cumulative incidence or risk in a second or reference group; also described as relative risk (Section 3.6). Reference group is surgeons.

5.6.5 Patients with an unplanned return to theatre or unplanned readmission Unplanned returns to theatre are strong predictors of death.[6] On average, 15% (608/4,053) of patients who died after an operation had had an unplanned return to theatre (Table 11). The percentage of patients who had an unplanned return to theatre has decreased since 2015, although this is not statistically significant (x2 = 5.56, p = 0.24).

Table 11: Unplanned returns to theatre, 2015–2020 (n=608) Year

Operated patients (n)

Unplanned returns to theatre (n)

% of total

2015–2016

891

148

16.6

2016–2017

840

123

14.6

2017–2018

864

131

15.2

2018–2019

855

132

15.4

2019–2020

603

74

12.3

Overall 2015-2020

4,053

608

14.8

Source: Surgical case form

The percentage of unplanned readmissions for patients who had an operation during 2015–2020 was low (2.8%; 111/4,027). This is comparable to previous years and is not statistically significant (x2 = 2.99, p = 0.56) (Table 12).

Table 12: Unplanned readmissions for patients who had an operation, 2015–2020 (n=111) Year

Operated patients (n)

Unplanned returns to theatre (n)

% of total

2015–2016

880

30

3.4

2016–2017

835

22

2.6

2017–2018

860

20

2.3

2018–2019

853

20

2.3

2019–2020

599

19

3.2

Overall 2015-2020

4,207

111

2.8

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5.6.6 Patients admitted to an intensive care unit Planned or unplanned admission to an intensive care unit (ICU) can occur at any time during a patient’s hospital stay regardless of whether they have an operation or not. Surgeons record whether the patient was admitted to ICU and the assessor comments on the appropriateness of the admission. (Note: some surgeons and assessors did not answer this question.)

Unplanned admission to ICU increases the risk of in-hospital mortality in very elderly patients (80 years and older).[7] At least 50.0% of the risk of in-hospital death in patients 80 years or older is attributable to a combination of unplanned ICU admission, comorbidity (≥1 comorbid condition), acute renal failure and respiratory failure.[7] Most QASM patients who died were 60 years or older.

Nearly 1 in 6 patients who died (16.7%; 851/5,099) had an unplanned admission to ICU in 2015–2020 (Figure 9; missing data n=64 [1.2%]). This percentage does not vary; the differences in unplanned admissions over the 5 years of the audit were not statistically significant (x2 = 4.05, p = 0.40).

Figure 9: All QASM patients with unplanned admissions to ICU, 2015–2020 (n=851)

Unplanned admissions to ICU (%)

20.0 18.0 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 2015–16

2016–17

2017–18

2018–19

2019–20

Year Reference: Appendix table 7

Of the patients who had an operation, 18.7% (755/4,039) required an unplanned admission to ICU (Figure 10). The rate of postoperative unplanned ICU admissions remained steady across the years and was not statistically significant (x2 = 4.05, p = 0.40), with the exception of 2016–2017 when 21.0% of operative patients had an admission to ICU.

100 90

Patients (%)

80 70 60 50 40 30 20 10

28

0 ROYAL AUSTRALASIAN COLLEGE OF SURGEONS 2010–11 2011–12 2012–13 2013–14 2014–15 2015–16 2016–17 2017–18 2018–19 2019–20

Year

25.0

20.0

15.0

ICU (%)

Operative patients with unplanned admission to

Figure 10: Operative QASM patients with unplanned admission to ICU, 2015–2020 (n=755)

10.0

5.0

0.0 2015–16

2016–17

2017–18

2018–19

2019–20

Year Reference: Appendix data table 8 Data missing n=31/4,070 (0.8%).

5.6.7 120 Patients with deep vein thrombosis prophylaxis Deep vein thrombosis (DVT) prophylaxis is given to most patients regardless of whether they have an operation.

100document any DVT prophylaxis used and assessors comment on the appropriateness of the usage.

Surgeons

Patients (n)

The percentage of cases given DVT prophylaxis was 81.9% (4,150/5,068); 18.1% (918/5,068) did not receive DVT 80 prophylaxis (data missing n=95/5,163 cases [1.8%]).

Surgeons60stated that they did not use DVT prophylaxis in the following situations: usage not appropriate—62.1% of patients (528/850) 40

active decision to withhold—34.8% of patients (296/850) 20 considered—3.1% of patients (26/850). usage not

Many surgeons gave additional reasons for not giving DVT prophylaxis. The most frequently cited reasons were that the 0 patient was: 0–10 11–20 21–30 31–40 41–50 51–60 61–70 71–80 81–90 91+ actively bleeding coagulopathic already anticoagulated

Age group (years) Male

Female

being palliated.

First and second-line assessors considered that DVT prophylaxis use was appropriate for most patients (83.1%; 4099/4,931), unknown for 14.9% (735/4,931) of patients and inappropriate for 2.0% (97/4,931) of patients (data missing n=232/5,163 cases [4.5%]). The number of patients who received inappropriate DVT prophylaxis decreased from 2.8% of patients (2015–2016) to 1.2% (2019–2020) (x2 = 6.56, p = 0.16).

Surgeons provided a DVT prophylactic agent on 8,678 occasions to 4,150 patients. The most frequently used DVT prophylaxis was heparin, in any form (Table 13).

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Table 13: Type of DVT prophylaxis provided to all QASM patients, 2015–2020 (n=4,150) Type of DVT prophylaxis

Patients

% of all prophylactic agents

Heparin — in any form

3,290

79.3

TED stockings

2,740

66.0

Sequential compression device

1,845

44.5

Aspirin

437

10.5

Other

252

6.1

Warfarin

114

2.7

8,678 uses of DVT prophylactic agent for 4,150 patients.

TED=thrombo-embolus deterrent

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ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

6 RESULTS: ABORIGINAL AND TORRES STRAIT ISLANDER PATIENTS In Australia, Aboriginal and Torres Strait Islander people experience poorer health outcomes compared with non‑Indigenous people.[8] The newly published RACS Indigenous health position paper reaffirms the RACS commitment to improving health outcomes for Aboriginal and Torres Strait Islander people.[8] Aboriginal and Torres Strait Islander people have higher rates of disease (cardiovascular disease, diabetes and chronic kidney disease), hospitalisation and death than do non-Indigenous people. These rates increase at a younger age in Aboriginal and Torres Strait Islander people than in non-Indigenous patients.[9] Adult Aboriginal and Torres Strait Islander people are more likely to have 3 or more comorbidities (38.0%) compared with adult non-Indigenous people (26.0%).[9] The following section compares characteristics and clinical outcomes of Aboriginal and Torres Strait Islander patients and non-Indigenous patients who had operations.

A total of 148 patients (2.9%; 148/5,163) identified as Aboriginal and Torres Strait Islander. Aboriginal and Torres Strait Islander patients were less likely to have an operation (83.0%; 122/147) than were non-Indigenous patients (96.9%; 3,948/5,011) (RR 1.1 [1.0–1.1]). (95% CI 1.0-1.1)).

Aboriginal and Torres Strait Islander patients were younger (by a median of 19 years); they were more likely to be transferred; and more likely to be emergency admissions to public hospitals than were non-Indigenous patients (Table 14). Aboriginal and Torres Strait Islander patients that were younger than 50 years were 3 times more likely to die following an operation than were non-Indigenous patients of the same age (RR 3.3 (95% CI 2.5-4.3).

Aboriginal and Torres Strait Islander patients were twice as likely to have 3 or more comorbidities per patient than non-indigenous patients. They were also 60.0% more likely to have fluid balance issues when in hospital than nonIndigenous patients (Table 14).

At the time of death, the presence of infections was not statistically different between Aboriginal and Torres Strait Islander and non-Indigenous patients. Aboriginal and Torres Strait Islander patients were more likely to have acquired the infection before admission to hospital (Table 14).

These findings indicate that Aboriginal and Torres Strait Islander patients could benefit from a different model of care.

A model including early recognition of health decline at primary care centres and early transfer for appropriate surgical intervention could lead to better outcomes for Aboriginal and Torres Strait Islander patients.

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Table 14: Characteristics and clinical outcomes of QASM Aboriginal and Torres Strait Islander and non-Indigenous patients who had operations, 2015–2020 Aboriginal and Torres Strait Islander patients (n=122) (%)

Non-Indigenous patients (n=3,948) (%)

Risk ratio** (95% CI) for Aboriginal and Torres Strait Islander patients

Age at death (years): • Mean (±SD) • Median (IQR) • Range

52.5 (21.5) 58.0 (43.0–66.0) 0–93

71.9 (18.8) 76.0 (65.0–85.0) 0–102

Age groups • 0-49 years

41/122

406/3,948

3.3 (2.5–4.3)*

• 50+ years

82/122

3,543/3,948

0.7 (0.7–0.8)

Transferred

52/122 (42.6)

1,049/ 3,879 (27.0)

1.6 (1.3–1.9)*

Public hospital admission

119/121 (98.3)

2,925/3,937 (74.3)

1.3 (1.2–1.4)*

Emergency admission

110/122 (90.2)

3,305/3,925 (84.2)

1.1 (1.0–1.1)*

Comorbidities present

108/121 (89.3)

3,519/3,937 (89.4)

1.0 (0.9–1.1)

one comorbidity

14/107 (8.9)

531/3,494 (15.2)

1.0 (0.5-1.6)

3 or more comorbidities

73/107 (68.2)

1,283/3,494 (36.7)

2.1 (1.8-2.4)*

Delays in diagnosis

11/122 (9.0)

300/ 3, 933 (7.6)

1.2 (0.7–2.1)

Postoperative complication

34/118 (28.8)

1,243/ 3,910 (31.8)

0.9 (0.7–1.2)

Fluid balance issue

22/121 (18.2)

414/3,905 (10.6)

1.7 (1.2–2.6)*

Clinically significant infection

41/121 (33.9)

1,375/3,894 (35.3)

1.0 (0.8–1.2)

Infection acquired before admission

21/40 (52.5)

535/1,349 (39.7)

1.3 (1.0–1.8)*

Infection acquired during admission

19/40 (47.5)

813/1,349 (60.3)

0.8 (0.5–1.1)

There is denominator variation as not all questions were answered. *Statistically significant but may not be clinically significant. ** Risk ratios are at 95% confidence interval. Risk ratio is the cumulative incidence or risk of disease in one group divided by the cumulative incidence or risk in a second or reference group, also described as relative risk (Section 3.6). Reference group is non-Indigenous patients.

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ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

Aboriginal and Torres Strait Islander patients had more comorbidities per patient than did non-Indigenous patients (Table 14 ). The distributions of the types of comorbidities differ, with Aboriginal and Torres Strait Islander patients more likely to have diabetes, renal disease and hepatic disease than are non-Indigenous patients (Table 15).

Table 15: Most frequently occurring comorbidities in QASM Aboriginal and Torres Strait Islander patients and nonIndigenous patients who had operations, 2015–2020 Aboriginal and Torres Strait Islander patients (n=107) (%)

Non-Indigenous patients (n=3,494) (%)

Risk ratios** (95% CI) for Aboriginal and Torres Strait Islander patients

Cardiovascular disease

67 (62.6)

2,337 (66.9)

0.9 (0.8–1.1)*

Diabetes

46 (43.0)

636 (18.2)

2.4 (1.9–3.0)*

Renal

47 (43.9)

1,095 (31.3)

1.4 (1.1–1.7)*

Other***

34 (31.8)

992 (28.4)

1.1 (0.9–1.5)

Respiratory

32 (29.9)

1,320 (37.8)

0.8 (0.6–1.1)

Hepatic

24 (22.4)

296 (8.5)

2.6 (1.8–3.8)*

Neurological

15 (14.0)

582 (16.7)

0.8 (0.5–1.4)

Obesity

18 (16.8)

450 (12.9)

1.3 (0.9–2.0)

Advanced malignancy

13 (12.1)

763 (21.8)

0.6 (0.3–0.9)*

Patients often have more than one comorbidity. Total of 10,883 comorbidities reported for 3,627 patients.

Missing data n=1 Aboriginal and Torres Strait Islander patients and n=85 non-Indigenous patients, total n=86 patients (0.3%), * Statistically significant ** Risk ratios are at 95% confidence interval. Risk ratio is the cumulative incidence or risk of disease in one group divided by the cumulative incidence or risk in a second or reference group, also described as relative risk (Section 3.7). Reference group is non-Indigenous patients ***Other includes alcohol abuse, anticoagulation, dementia/Alzheimer’s, depression, frailty, immunosuppression, leukemia, malnutrition, paraplegia, peripheral vascular disease, rheumatoid arthritis, smoking.

Source: Surgical case form

Surgeons consider many factors when deciding to operate; the benefits of an operation must outweigh the risks. The distribution of surgical specialties under which patients were admitted and the percentage of those patients who received an operation differs between Aboriginal and Torres Strait Islander patients and non-Indigenous patients (Table 16).

All Aboriginal and Torres Strait Islander patients admitted under vascular and paediatric surgeons received an operation. Aboriginal and Torres Strait Islander patients admitted under a Neurosurgeon were 20.0% more likely to have an operation than were non-Indigenous patients. Fewer Aboriginal and Torres Strait Islander patients were admitted under orthopaedic surgeons than were non-Indigenous patients although the same percentage of patients had an orthopaedic operation.

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Table 16: The distribution of QASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients admitted by surgical specialty and the percentage who had an operation, 2015–2020 Specialty

Aboriginal and Torres Strait Islander patients (n=148) (%)

Non-Indigenous patients (n=5,015) (%)

Risk ratios** (95% CI) for Aboriginal and Torres Strait Islander patients

General

36/52 (69.2)

1,293/1,824 (70.9)

1.0 (0.8–1.2)

Cardiothoracic

22/26 (84.6)

396/416 (95.2)

0.8 (1.8–1.0)

Neurosurgery

19/23 (82.6)

477/695 (68.6)

1.2 (1.0–1.5)*

Vascular

22/22 (100.0)

399/453 (88.1)

1.1 (1.1–1.2)*

Orthopaedic

11/13 (84.6)

1,013/1,204 (84.1)

1.0 (0.8–1.3)

Paediatric

6/6 (100.0)

44/45 (97.8)

1.0 (1.0–1.1)*

Specialities are not reported where numbers are very low (fewer than 5). * Statistically significant ** Risk ratios are at 95% confidence interval. Risk ratio is the cumulative incidence or risk of disease in one group divided by the cumulative incidence or risk in a second or reference group, also described as relative risk (Section 3.7). Reference group is non-Indigenous patients

Aboriginal and Torres Strait Islander patients who had an operation were nearly twice as likely to die following vascular and cardiothoracic operations than were non-Indigenous patients (Table 17).

The increased risk of death following vascular operations could be due to the increased frequency of diabetes and diabetic peripheral neuropathy in Aboriginal and Torres Strait Islander patients. Similarly, the increased risk of death following a cardiothoracic operation could be due to the cardiovascular disease itself or the late presentation for cardiothoracic operations in Aboriginal and Torres Strait Islander patients.

Paediatric Aboriginal and Torres Strait Islander patients were four times as likely to die following an operation compared with non-Indigenous paediatric patients. However, this increased risk of death needs to be interpreted with caution due to the low number of patients.

The lower risk of death for Aboriginal and Torres Strait Islander patients following orthopaedic operations (where patient median ages generally tend to be higher) could be due to the younger average age of the Aboriginal and Torres Strait Islander patients who died having had an orthopaedic operation.

Table 17: The percentage of QASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients who had operations, 2015–2020 Specialty

Aboriginal and Torres Strait Islander patients (n=122) (%)

Non-Indigenous patients (n=3,948) (%)

Risk ratios** (95% CI) for Aboriginal and Torres Strait Islander patients

General

36 (29.5)

1,293 (32.7)

0.9 (0.7–1.2)

Cardiothoracic

23 (18.9)

396 (10.0)

1.8 (1.2–2.7)*

Vascular

22 (18.0)

399 (10.1)

1.8 (1.2–2.6)*

Neurosurgery

19 (15.6)

477 (9.5)

1.3 (0.9–2.0)

Orthopaedic

11 (9.0)

1,013 (20.2)

0.4 (0.2–0.6)*

Paediatric

6 (4.9)

44 (0.9)

4.4 (1.9–10.2)*

Specialities are not reported where numbers are very low (fewer than 5). * Statistically significant ** Risk ratios are at 95% confidence interval. Risk ratio is the cumulative incidence or risk of disease in one group divided by the cumulative incidence or risk in a second or reference group, also described as relative risk (Section 3.7). Reference group is non-Indigenous patients

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ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

All of the 148 Aboriginal and Torres Strait Islander patients’ surgical deaths reported to QASM had an FLA. An SLA was completed for 18.9% of patients (28/148). This was significantly more than the 14.1% for non-Indigenous patients’ deaths (728/5,171) (RR 1.3; 95%CI 1.0–1.9). Assessors considered that most patients did not have any CMIs. Of the 122 Aboriginal and Torres Strait Islander patients who had operations, first- and second-line assessors reported that 24.6% of patients (30/122) had a total of 30 CMIs. These CMIs were considerations (n=12), concerns (n=13) and 5 adverse events. Of the adverse events, 3 caused the death of the patient and 4 events were preventable.

The adverse events were: post-operative bleeding after open surgery ureteric complication of endoscopic operation anticoagulation causing post-operative bleeding diagnosis missed by medical unit delay in recognising complications

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7

OUTCOMES OF PEER-REVIEW ASSESSMENTS

All 5,163 of the surgical deaths included in this report had an FLA. An SLA was completed for 756 patient cases (14.6%; 756/5,163). Insufficient clinical information in the SCF was the reason for most SLA requests (63.8%; 482/756).

7.1

Assessor-identified clinical management issues

CMIs may be classed as:

an area of consideration (the least serious level of concern), an area of concern, or an adverse event (the most serious level of concern).

CMIs in this report are those from the highest assessor (i.e. if the case had both a first- and second-line assessment review, the included CMI is that from the SLA). Some patients had more than one CMI. For these patients, the CMI with the most serious level of concern was included in the analysis for this report (section 3.4).

First- and second-line assessors considered that most patients (80.7%; 4,076/5,050) had no CMIs (data not answered by assessors n=113/5,163; 2.2%). Assessors identified CMIs in 974 patients (19.3%; 974/5,050), who had a combined total of 1,002 CMIs. Most of the CMIs (64.3%; 644/1,002) were areas of consideration (the least serious level of concern); a quarter were areas of concern (25.5%; 256/1,002) and 10.2% (102/1,002) were adverse events — the most serious level of concern.

Assessors are asked to consider if the CMI had any effect on the patient’s outcome. Assessors considered that more than half (57.9%) of the CMIs may have contributed to the outcome (570/984), a third made no difference to the outcome (32.6%; 321/984) and 9.5% (93/984) caused the death of the patient.

Assessors also consider if the CMIs were preventable. Assessors considered that 57.4% (542/945) of CMIs were preventable and, of these, 28.6% (155/542) were definitely preventable.

More than half of the CMIs (56.9%; 488/857) were associated with the audited surgical team; nearly one-third were associated with another clinical team (31.5%; 270/857). A small percentage of CMIs were associated with hospital processes (5.3%; 45/857) (Figure 11).

Figure 11: Clinical team or facility associated with clinical management issue, 2015–2020 (n=857)

5.3%

6.3%

31.5%

Surgical team

Another clinical team

56.9%

Hospital process

*Other

* Other associations specified by surgeons: anaesthetics team (n=4; 0.2%), another hospital (n=3; 0.1%), ICU (n=2; 0.1%), surgeon (n=1; <0.1%), emergency department (n=1; <0.1%), general practitioner (n=1; <0.1%), medical team (n=1; <0.1%), need for transfer to ICU care (n=1; <0.1%), transfer team (n=1; <0.1%). Not all surgeons reported associations with clinical incidents.

Source: Surgical case form Reference: Appendix data table 9

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ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

The most frequently reported CMIs by both first- and second-line assessors were *: Decision to operate (13.8%; 138/1,002) area of consideration (81.9%; 113/137) decision to operate may have contributed to death (37.0%; 51/135) preventable death due to the decision to operate (48.0%; 59/123).

Better to have done a different operation or procedure (10.8%; 108/1,002) Delay to surgery when an earlier operation was desirable (8.3%; 83/1,002) D elay in surgical diagnosis (6.3%; 63/1,002). Delay was mostly due to an incorrect test being performed (81.3%; 13/16), unavoidable circumstances (75.0%; 12/16), or misinterpretation of results (71.4%; 15/21). Delays in in diagnoses were associated with both the medical (80.0%; 20/25) and surgical teams (72.2%; 13/18).

Postoperative care unsatisfactory (3.7%; 37/1,002). *Note: denominators vary because not all questions were answered completely.

7.2

Assessor-identified areas of concern

Of the 256 CMIs considered to be areas of concern, assessors considered that most (80.9%; 203/251) may have contributed to the outcome, 13.1% (203/251) made no difference to the outcome and 6.0% (15/251) caused the death of the patient. Assessors considered that 79.7% (200/247) of the CMIs were preventable and, of these, 70.0% (140/200) were probably preventable and 30.0% were definitely preventable (60/200). Most of the CMIs considered to be areas of concern were associated with either the surgical team (46.8%; 110/235) or another clinical team (40.9%; 96/235). A few were associated with a hospital process (6.0%; 14/235).

The 5 most frequent areas of concern account for 43.3% of all areas of concern. These were: delay to surgery (i.e. earlier operation desirable) (12.9%; 33/256) delay in diagnosis (9.4%; 24/256) better to have done different operation or procedure (8.2%; 21/256) decision to operate (8.2%; 21/256) postoperative care unsatisfactory (4.7%; 12/256).

7.3

Assessor-identified adverse events

Assessors considered that over half (52.9%; 54/102) of the adverse events caused the death of the patient and 41.2% (42/102) may have contributed to the outcome. Assessors considered that 75.0% (75/100) of the adverse events were preventable and, of these, 46.7% (35/75) were definitely preventable. Most of the adverse events were associated with either the surgical team (52.1%; 49/94) or another clinical team (36.2%; 34/94). A few adverse events were associated with a hospital process (6.4%; 6/94).

Of the 102 CMIs considered adverse events, the most frequent were: delay in diagnosis (6.9%, 7/102) aspiration pneumonia (5.9%, 6/102) postoperative care unsatisfactory (4.9%,5 /102) better to have done a different procedure (3.9%, 4/102)

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Assessors identified the number of adverse events is decreasing over the report years, from 26 (2.6%) in 2015–2016 to 12 (1.2%) in 2019–2020 (x2 = 8.97, p = 0.16) (Figure 12).

Adverse events (%)

Figure 12: Percentage of adverse events over time, 2015–2020 (n=102)

3.0 2.5 2.0 1.5 1.0 0.5 0.0 2015–16

2016–17

2017–18

2018–19

2019–20

Year Source: Surgical case form Reference: Appendix data table 10

7.4

Preventable clinical management issues

Assessors determined if CMIs were definitely or probably preventable. Of the 542 preventable CMIs, assessors identified overall more in postoperative situations (17.0%; 92/542) than in preoperative situations (14.8%; 80/542) or intraoperative situations (7.4%; 40/542). (Data not answered by assessors n=57/1,002; 5.7%). The number of preventable CMIs in each group remained similar over the years.

The most frequent preventable CMIs were: decision to operate (10.9%, 59/542) better to have done different operation or procedure (10.7%, 58/542) delay to surgery (i.e. earlier operation desirable) (9.6%, 52/542) delay in diagnosis (7.4%, 40/542) postoperative care unsatisfactory (4.6%, 25/542) preoperative assessment inadequate (3.0%, 16/542) delay in transfer to tertiary hospital (2.4%, 13/542) unsatisfactory medical management (2.0%, 11/542) delay in recognising complications (1.3%, 7/542) failure to use high dependency unit (1.3%, 7/542)

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ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

Over the 5-year report period, assessors classified 75 (13.8%; 75/542) definitely or probably preventable CMIs as adverse events.). These CMIs were serious, unintended injuries caused by medical management rather than by the disease process, which led to prolonged hospitalisation and contributed to, or caused, the death of the patient.

The most common preventable adverse events were: delay in diagnosis (9.3%, 7/75) postoperative care unsatisfactory (6.7%, 5/75) better to have done different operation or procedure (5.3%, 4/75) decision to operate (4.0%, 3/75) preoperative assessment inadequate (4.0%, 3/75) aspiration pneumonia (2.7%, 2/75) In response to these findings, QASM is preparing one-page reports on the decision to operate and aspiration pneumonia. Both reports will be presented to all surgeons and surgical staff across Queensland.

Appendix data table 11 provides a complete list of preventable adverse events that occurred during the 5 years of the audit.

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8 REFERENCES 1. Royal Australasian College of Surgeons. Australian and New Zealand Audit of Surgical Mortality National Report 2016. Adelaide Royal Australasian College of Surgeons; 2017.

Available from: https://www.surgeons.org/-/media/Project/RACS/surgeons-org/files/surgical-mortality-audits/ anzasm-reports/2017-10-05_rpt_racs_anzasm_national_report_2016.pdf 2. Queensland Health, Statistical Services Branch. Queensland Hospital Admitted Patient Data Collection (QHAPDC): Admission and separation date/time. State of Queensland (Queensland Health). 2017 [accessed 30 June 2021].

Available from: https://www.health.qld.gov.au/__data/assets/pdf_file/0026/656423/info-sheet-adm-sepv1.0.pdf 3. Australian Institute of Health and Welfare. Table 6.3: Interventions reported for the 20 most common ACHI procedure blocks for overnight acute separations, public and private hospitals, 2017–18. [accessed 06 February 2021]. Available from: https://www.aihw.gov.au/reports/hospitals/admitted-patient-care-2017-18/data 4. North J, Blackford F, Wall D, Allen J, Faint S, Ware R, et al. Analysis of the causes and effects of delay before diagnosis using surgical mortality data. Br J Surg. 2013;100(3):419–425.

Available from: https://academic.oup.com/bjs/article/100/3/419/6138349 5. American Society of Anesthesiologists. ASA physical status classification system. Developed by ASA House of Delegates/Executive Committee [original approval 15 October 2014; updated 13 December 2020].

Available from: https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system 6. Lefaivre K, Macadam S, Davidson D, Gandhi R, Chan H, Broekhuyse H. Length of stay, mortality, morbidity and delay to surgery in hip fractures. J Bone Joint Surg Br. 2009;91(7):922-927.

Available from: https://online.boneandjoint.org.uk/doi/full/10.1302/0301-620X.91B7.22446 7. F rost S, Davidson P, Alexandrou E, Hunt L, Salamonson Y, Tam V, et al. Unplanned admission to the intensive care unit in the very elderly and risk of in-hospital mortality; Crit Care Resus; 2010; (3):171–176. PMID: 21261574.

Available from: https://pubmed.ncbi.nlm.nih.gov/21261574/ 8. Royal Australasian College of Surgeons. Indigenous Health Position Paper June 2020.

Available from: https://www.surgeons.org/en/News/News/Updated-Indigenous-Health-position-paper 9. Australian Institute of Health and Welfare. Cardiovascular disease, diabetes and chronic kidney disease—Australian facts: Aboriginal and Torres Strait Islander people. Cardiovascular, diabetes and chronic kidney disease series no. 5.

Cat. no. CDK 5. Canberra: AIHW. 2015 [accessed 16 August 2021].

Available from: https://www.aihw.gov.au/getmedia/e640a6ba-615c-46aa-86d3-097d0dc1d0c3/19548.pdf. aspx?inline=true

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ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

APPENDIX 1: What surgeons report they would have done differently The following is a sample of statements made by surgeons regarding what they would have done differently (in response to question 25 of the SCF).

Consideration for transcatheter aortic valve implantation Logistics for transfer to city Hypoproteinemia in critically unwell patient Discussed with family and referring cardiologist Not to operate because of her age!

In retrospect, I would not have operated, but these are very difficult decisions to make as stabilising an unstable spine almost becomes a palliative procedure if the patient is not thought to be imminently dying. It did not appear as if this patient was at imminent risk of death, so a decision was made to operate. In retrospect this was the wrong decision. It unlikely made a difference to survival as without surgery and lying flat the patient would likely have succumbed to aspiration hence the reason to operate.

Although the patient had significant head injuries, the traumatic pseudoaneurysm of the descending thoracic aorta was the immediate threat to life. The patient was able to consent to the procedure and the impression was that he might recover from the head injury but would not survive the thoracic aortic injury. The patient was also known to be active on his farm; hence the decision to proceed. With hindsight, his head injuries were severe, and it would be unlikely that he would make a full recovery (at his age) from the injuries.

Prior to admission constipation could have been better controlled long term Earlier institution of acute resuscitation plan.

Maybe declined to operate on this old lady.

Not sent her to ICU! Elderly person with multiple comorbidities with significant blunt chest injury was likely to develop clinical sequelae from pulmonary contusion. Unfortunately, this was a stoic gentleman who looked and behaved well initially and fooled everyone into a false sense of reassurance. Could I have forced the intensivist to accept the patient from the emergency department? Would it have made any difference to outcome?

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APPENDIX 2: Data tables Denominators in this report sometimes differ because not all questions were answered for each patient.

Data presented in this report have been collected from SCFs submitted between 1 July 2015 and 30 June 2020 (census date 1 October 2020).

Appendix data table 1: Status of all QASM cases at time of census, 2015–2020 (n=6,413*) Status

n (%)

SCF pending

183 (2.9)

SCF incomplete

2 (0.0)

FLA pending

50 (0.8)

SLA pending

37 (0.6)

Reviewed

5,163 (80.5)

Closed — non-participant

1 (0.0)

Excluded — terminal care

751 (11.7)

Excluded — error

188 (2.9)

SCF submitted

2 (0.0)

SCF rejected

1 (0.0)

FLA incomplete

2 (0.0)

SLA incomplete

1 (0.0)

Lost to follow-up

5 (0.1)

Medical records pending

16 (0.2)

Medical records received

8 (0.1)

Feedback letter pending

3 (0.0)

Total

6,413 (100.0)

FLA=first-line assessment; SLA=second-line assessment; SCF=surgical case form *Missing data n=272 *Note: Only surgical deaths that have completed the audit review process and have a status of ‘reviewed’ were analysed in this report.

Appendix data table 2: Notifications of surgical deaths in reviewed QASM cases by year, 2015–2020 (n=5,163) Year

n (%)

2015–2016

1,121

2016–2017

1,084

2017–2018

1,104

2018–2019

1,077

2019–2020

777*

*2019–2020 cases are lower because 175 (3.4%) cases are still pending.

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ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

Appendix data table 3: Age of QASM patients in 20-year age groups, 2015–2020 (n=5,163) Age group (years)

n (%)

0–19

140 (2.7)

20–39

166 (3.2)

40–59

623 (12.1)

60–79

2,126 (41.2)

80–99

2,094 (40.6)

100+

14 (0.3)

Total

5,163 (100.0)

Appendix data table 4: Delays in QASM surgical diagnoses by year, 2015–2020 (n=345) Year

n (%)

2015–2016

82 (7.4)

2016–2017

64 (5.9)

2017–2018

81 (7.4)

2018–2019

77 (7.2)

2019–2020

41 (5.3)

Appendix data table 5: ASA class recorded for QASM patients, 2015–2020 (n=4,555*) ASA class

n (%)

1

64 (1.4)

2

243 (5.3)

3

1,467 (32.2)

4

2,144 (47.1)

5

601 (13.2)

6

36 (0.8)

Total

4,555 (100.0)

*Missing data n=608 patients ASA = American Society of Anaesthesiologists. ASA class 1 = a normal healthy patient; ASA class 2 = a patient with mild systemic disease; ASA class 3 = a patient with moderate systemic disease; ASA class 4 = a patient with severe systemic disease that is a constant threat to life; ASA class 5 = a moribund patient unlikely to survive 24 hours, who is not expected to survive without an operation; ASA class 6 = a patient declared brain dead whose organs are being removed for donor purposes.

Appendix data table 6: QASM postoperative complications by year, 2015–2020 (n=1,277) Year

n (%)

2015–2016

310 (35.0)

2016–2017

272 (32.7)

2017–2018

277 (32.4)

2018–2019

254 (29.8)

2019–2020

164 (27.2)

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Appendix data table 7: All QASM patients with unplanned admission to ICU by year, 2015–2020 (n=851) Year

n (%)

2015–2016

179 (16.2)

2016–2017

198 (18.5)

2017–2018

175 (16.2)

2018–2019

172 (16.1)

2019–2020

127 (16.5)

Appendix data table 8: QASM operative patients with unplanned admission to ICU by year, 2015–2020 (n=755) Year

n (%)

2015–2016

163 (18.4)

2016–2017

176 (21.0)

2017–2018

156 (18.2)

2018–2019

149 (17.4)

2019–2020

111 (18.5)

Appendix data table 9: Clinical team or facility associated with QASM CMI, 2015–2020 (n=857) Associated clinical team or facility

n (%)

Audited surgical team

488 (56.9)

Another clinical team

270 (31.5)

Hospital processes

45 (5.3)

Other*

54 (6.3)

*Other associations specified by surgeons: anaesthetics team (n=4; 0.2%), another hospital (n=3; 0.1%), ICU (n=2; 0.1%), surgeon (n=1; <0.1%), emergency department (n=1; <0.1%), general practitioner (n=1; <0.1%), medical team (n=1; <0.1%), need for transfer to ICU care (n=1; <0.1%), transfer team (n=1; <0.1%). Not all surgeons reported associations with clinical incidents.

Appendix data table 10: Percentage of clinical management issues that were adverse events by year, 2015–2020 (n=102) Year

44

n (%)

2015–2016

26 (2.6)

2016–2017

28 (2.8)

2017–2018

16 (1.6)

2018–2019

20 (2.6)

2019–2020

12 (1.2)

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

Appendix data table 11: Definitely and probably preventable adverse events associated with QASM CMI, 2015–2020 (n=75) Preventable adverse event

Number of events

Delay in diagnosis

7

Postoperative care unsatisfactory

5

Better to have done different operation or procedure

4

Decision to operate

3

Preoperative assessment inadequate

3

Aspiration pneumonia

2

Delay in recognising complications

2

Delay to operation (i.e. earlier operation desirable)

2

Perforation of colon during endoscopic operation

2

Postoperative bleeding after open surgery

2

Surgeon too junior

2

Venous bleeding related to open surgery

2

Anastomotic leak from colon after laparoscopic operation

1

Anticoagulation causing postoperative bleeding

1

Arterial complication of open surgery

1

Cardiac complication during general anaesthetic

1

Delay in recognising cardiac complication

1

Delay in reviewing test results

1

Delay in transfer to surgeon by physicians

1

Delay in transfer to tertiary hospital

1

Delay in X-ray department

1

Delay to operation caused by missed diagnosis

1

Diagnosis missed by medical unit

1

Displacement of tracheostomy tube

1

Drug interaction

1

Failure to stop intraoperative bleed during open surgery

1

Failure to insert a drain

1

Failure to recognise severity of illness

1

Failure to use high dependency unit

1

Incorrect use of drains or catheters

1

Injury caused by fall in hospital

1

Injury to heart during endoscopic operation

1

Injury to heart during open surgery

1

Injury to lung during endoscopic operation

1

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Appendix data table 11: Definitely and probably preventable adverse events associated with QASM CMI, 2015–2020 (n=75) Preventable adverse event

46

Number of events

Injury to ureter during open surgery

1

More aggressive treatment of infection needed

1

Nasogastric tube not used

1

Over-anticoagulation

1

Over-anticoagulation during admission

1

Perioperative cerebral ischaemia or infarction

1

Poor documentation on medication chart

1

Postoperative bleeding due to coagulopathy

1

Pulmonary artery rupture due to intravenous line insertion

1

Respiratory tract complication of radiological operation

1

Septicaemia – cause unspecified

1

Surgeon operating without specialty

1

Transfer should not have occurred

1

Unsatisfactory medical management

1

Vascular injury to colon during laparoscopic operation

1

Wrong drug dosage used

1

Wrong drug used

1

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

APPENDIX 3: Definitions 1.

Surgical Case Form (SCF): A structured questionnaire completed by the surgeon associated with the case.

Surgeons enter SCF responses into an online database—the RACS Audit of Surgical Mortality Fellows Interface (Fellows Interface).

2.

First-line assessment (FLA): Case assessment conducted by a surgeon from the same speciality as the reporting surgeon. The first-line assessor reviews the SCF (not patient files) and enters responses into the Fellows Interface. The first-line assessor will either close the case or recommend further assessment by a second-line assessor.

3.

Second-line assessment (SLA): Case assessment conducted by a surgeon from the same speciality as the reporting surgeon. Second-line assessors are generally specialists in the area under review. First‑ and secondline assessors respond to the same set of questions; however, SLAs are more in-depth, as these assessors have access to the case medical record. QASM provides second-line assessors a letter summarising issues to be addressed in their report.

4. Cases may be referred for an SLA if:

 an area of concern or adverse event is thought to have occurred during the patient’s clinical care and warrants further investigation

 the patient’s death was unexpected (i.e. a healthy patient not expected to die)  information provided by the surgeon was insufficient to reach a conclusion in the FLA

 an SLA report could highlight aspects of surgical practice and provide an educational opportunity for the surgeon involved and/or a wider audience via publication as a case note review.

5. A surgeon can appeal the findings of an SLA, in which case an additional independent second-line assessor is selected. This has not occurred in QASM since its inception in 2007.

6.

Separation is the process by which an episode of care for an admitted patient is completed. A separation may be formal or statistical. An episode of care may be completed because the patient’s treatment is complete, the patient no longer requires care, the patient has died or is transferred to another hospital/care facility or leaves the hospital against medical advice.[2] 7.

Operation is used to refer to operations and procedures (i.e. in this report, an operation may refer to a relevant radiological or endoscopic procedure as well as a surgical procedure).

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Notes ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

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ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

Notes ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

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