ACTASM Report 2017

Royal Australasian College of Surgeons Australian Capital Territory Audit of Surgical Mortality (ACTASM)

REPORT 2017

Contact Royal Australasian College of Surgeons Australian Capital Territory Audit of Surgical Mortality (ACTASM) Suite 31, 2 King Street Deakin, ACT 2600 Australia Telephone: +61 2 6285 4558 Facsimile:

+61 2 6285 3366

Email: actasm@surgeons.org Website: www.surgeons.org/actasm The information contained in this report has been prepared under the auspices of the Royal Australasian College of Surgeons, Australian Capital Territory Audit of Surgical Mortality Management Committee, which is a declared quality assurance committee under the Health Act 1993.

The information contained in this report has been prepared by the Royal Australasian College of Surgeons, Australian Capital Territory Audit of Surgical Mortality Management Committee. The Australian and New Zealand Audit of Surgical Mortality, including the Australian Capital Territory Audit of Surgical Mortality, has protection under the Commonwealth Qualified Privilege Scheme under Part VC of the Health Insurance Act 1973 (Gazetted 25 July 2016)

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CONTENTS Chairman’s report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Shortened Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Executive Summary – ACTASM 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Comparison With National Data 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1. Recommendations & Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 2. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 3. Audit And Reporting Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 4. Audit Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 5. Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6. Patient Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 7. Hospital Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

7.1 Hospital Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

7.2 Operative and Non-operative deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

7.3 Risk Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

7.4 Interhospital Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 8. Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

8.1 Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

8.2 Postoperative complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

8.3 Causes of Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 9. Clinical Management Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 10. Final Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 11. Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 12. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Figures Figure 1: Figure 2: Figure 3: Figure 4: Figure 5: Figure 6: Figure 7:

Australian Capital Territory Audit of Surgical Mortality (ACTASM) methodology . . . . . . . . . . . 9 Audit status — cases at census date per year . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Length of stay per year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Urgency classification of operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Proportion of cases with active decision not to operate . . . . . . . . . . . . . . . . . . . . . . 14 Proportion of infections acquired prior to or during admission, 2012 to 2017 . . . . . . . . . . . 15 Postoperative complications by admission status and audit period, 2012 to 2017 . . . . . . . . 16

Figure 8: Cases with one or more serious clinical management issue (CMI), by audit period, 2012 to 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Figure 9: Areas identified by assessors for management improvement . . . . . . . . . . . . . . . . . . . 18 Figure 10: Cases with serious clinical management issue (CMI) by admission type, 2012 to 2017 . . . . . . 19

Tables Table 1:

ACTASM and national comparison, 2017 audit period . . . . . . . . . . . . . . . . . . . . . . . 6

Table 2:

Type of clinical infection reported in 2016 and 2017 . . . . . . . . . . . . . . . . . . . . . . . 15

Table 3:

Timing of infections acquired during admission in 2016 and 2017 . . . . . . . . . . . . . . . . 16

Australian Capital Territory Audit of Surgical Mortality (ACTASM) Report 2017

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CHAIRMAN’S REPORT I am pleased to present the seventh Australian Capital Territory Audit of Surgical Mortality (ACTASM) annual report.

ACTASM continues to pride itself on being a comprehensive quality assurance tool that provides an educational platform for improving surgical practice. To continue efforts in improving feedback loops and transparency, the inaugural Hospital Performance Reports were developed and released in 2017. These reports provide a practical tool for hospitals (that meet the inclusion criteria) to identify how they compare to like hospitals nationally for identified clinical management issues. This new report, coupled with the hospital specific Clinical Governance Report, provides a comprehensive overview of trends in clinical management issues, enabling hospital administrators to work with relevant stakeholders to improve surgical outcomes.

Second-line assessments provide an in-depth review of cases and include clinical recommendations from peers. This is a great opportunity for colleagues to pool skills and knowledge and learn from one another, both individually through direct surgeon feedback and more broadly via the Case Note Review Booklet. There was a marked increase in second-line assessments in 2017.

While our results on mortality overall are in line with national outcomes, we have observed an increase in some clinically significant infections, including pneumonia, and this is an area where we could improve. There has also been an increase in the number of preventable clinical management issues compared with previous years, and this is an issue that individual surgeons should address. On an encouraging note, fluid management problems remain well under the national average.

ACTASM is committed to being proactive and innovative. We are open to recommendations that will help us enhance audit processes and maximise the positive impact of the audit for the health system and key stakeholders.

It is with sadness that I note that Angie Clerc-Hawke is leaving the team, and I wish her all the best for the future.

Finally, I would like to thank the Australian Capital Territory (ACT) Department of Health and the Royal Australasian College of Surgeons (RACS) for their support of ACTASM, as the audit would not be possible without this assistance. I would also like to extend my gratitude to all my colleagues who have assisted ACTASM by promptly submitting case forms, assessing cases, serving on the management committee, or who have contributed to the workshops. The audit can only thrive if we continue to enjoy this high level of support from all of you.

Dr John Tharion Clinical Director

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Royal Australasian College of Surgeons

SHORTENED FORMS ACT

Australian Capital Territory

ACTASM

Australian Capital Territory Audit of Surgical Mortality

ANZASM

Australian and New Zealand Audit of Surgical Mortality

ANZCA

Australian and New Zealand College of Anesthetists

ASA

American Society of Anesthesiologists

CMI

Clinical management issue

DVT

deep vein thrombosis

RAAS

Research, Audit and Academic Surgery

RACS

Royal Australasian College of Surgeons

RANZCOG

Royal Australian and New Zealand College of Obstetricians and Gynaecologists

Australian Capital Territory Audit of Surgical Mortality (ACTASM) Report 2017

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EXECUTIVE SUMMARY – ACTASM 2017 The Australian Capital Territory Audit of Surgical Mortality (ACTASM) is an audit process that provides an independent, external peer review of all surgically-related deaths within the Australian Capital Territory (ACT). It is systematic, objective and confidential, and its purpose is to inform and improve surgical practice, with the ultimate goal of improving the quality of patient care.

95%

Participation

Surgeons (mandatory)

100%

50%

Public & Private Hospitals

Gynaecologists (voluntary)

Patients

75

62%:38%

mean age

Male:Female

Risk Profile

86%

73

mean age

68%

ASA 4 or higher

admitted as emergencies

86%

had one or more comorbidities

73% of patients had at least one operation

Of these 23%, had more than one operation

23%

73%

27%

Surgical patient - no operation

4

Operations

61%

Consultant performed operation

16%

unplanned return to OR

Royal Australasian College of Surgeons

26%

of cases were transferred into audited hospital

Transfers 100%

had sufficient clinical documentation

2

transfer cases raised issues of delay from pre-transfer hospital

74%

of patients received care in a Critical Care Unit

Risk Management 3%

91%

of cases identified fluid balance issues

DVT prophylaxis used in cases

40%

of patients died with a clinically significant infection

Infection

these infections were

18% Pneumonia 10% Intra-

abdominal sepsis

6% Septicaemia 90%

of cases had minor or no issues identified

Peer review outcomes

10%

of cases had serious issues identified

100

of cases had individual surgeon feedback provided

22%

of all issues were considered definitely preventable

Feedback

2

hospitals had clinical governance reports provided Australian Capital Territory Audit of Surgical Mortality (ACTASM) Report 2017

Fourth edition of Case Note Review Booklet circulated

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COMPARISON WITH NATIONAL DATA 2017 Table 1: ACTASM and national comparison, 2017 audit period Areas for comparison

ACTASM

ANZASM

95.0%

98.2%

109

2,697

12.8%

9.9%

62.4% 37.6%

56.0% 44.0%

74 and 77

76 and 78

ASA status ≼ 4

68.4%

64.5%

Admitted with one or more comorbidities

86.2%

89.5%

Cases with perceived risk of death considerable or expected (as perceived by the assessor)

59.0%

68.5%

Admissions: Emergency Elective

86.2% 13.8%

87.0% 13.0%

Issues with fluid balance

2.8%

7.3%

73.4%

79.8%

Patients with unplanned return to theatre

16.3%

14.7%

Patients with postoperative complications

36.3%

29.5%

Patients with anaesthetic-related issues

3.8%

1.8%

Procedures abandoned

5.8%

5.8%

Patients transferred

26.0%

25.7%

Total number of clinically significant infections

40.2% (43/107)

35.0%* (938/2,677)

Infections acquired before admission

43.9% (18/41)

44.9%* (413/919)

Infections acquired during admission

56.1% (23/41)

55.1%* (506/919)

Areas of concern and adverse events

10.3%

8.2%

AUDIT Surgeon participation Closed cases at year end Cases sent to second-line assessment PATIENT Gender: Male Female Median age for males and females (years)

HOSPITAL CARE

Patients who had one or more procedures^

CLINICAL MANAGEMENT ISSUES

ACTASM: Australian Capital Territory Audit of Surgical Mortality; ANZASM: Australian and New Zealand Audit of Surgical Mortality; ASA: American Society of Anesthesiologists.

Note: data is comprised of cases closed as of the census date. ^Audit patients who underwent an episode of surgery either during their final admission or within 30 days prior to death. *Excludes New South Wales data

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Royal Australasian College of Surgeons

1. RECOMMENDATIONS & KEY POINTS These ACTASM recommendations were developed following analysis of data collected through the audit.

Although these recommendations were developed for the ACT, they strongly reflect issues arising around the country, as seen through the Australian and New Zealand Audit of Surgical Mortality (ANZASM).

Recommendation 1: Infections Although hospital and community acquired infections have remained steady between 2016 and 2017, there was a 17% increase in the number of cases in which pneumonia was identified as the cause of a clinically significant infection.

It is recommended that a system be developed and implemented in line with National Safety and Quality Health Service (NSQHS) Standards1and include; processes for reporting, investigating and analysing the management of pneumonia, and align these systems and processes with organisational risk management strategies.

Recommendation 2: Preventable clinical management issues (CMI) In 2017, 26 of 107 cases identified with CMIs, 67% were determined to be definitely or probably preventable.

This is a marked increase from 2016 where 46% of cases were definitely or probably preventable.

It is recommended that surgeons are encouraged to share learning with surgical colleagues. The finding and recommendations should be discussed at relevant meetings.

Recommendation 3: Areas for management improvement Postoperative care is an area that assessors continue to identify as requiring management improvement.

It is recommended that surgeons and other clinicians should carefully consider whether their patients would benefit from admission to a critical care unit.

2. BACKGROUND The ACTASM is the ACT regional component of ANZASM, a nation-wide, independent peer-review audit that seeks to identify deficiencies of care that lead to surgical mortality. It identifies system or process errors and deficiency of care trends, and helps develop strategies to reduce deaths in the surgical arena, both locally and across Australia. The process involves self-reporting by surgeons and peer review by first- and second-line assessors.

The ACTASM is managed by the Royal Australasian College of Surgeons (RACS), with funding and support provided by ACT Health. The ACTASM project falls under the governance of the ANZASM Steering Committee.

The project has been gazetted as a Quality Assurance activity under the Commonwealth Qualified Privilege Scheme under Part VC of the Health Insurance Act 1973 (gazetted 25 July 2016). This was updated in 2013 to include Australian and New Zealand College of Anaesthetists (ANZCA) Fellows.

Participation in the ANZASM is a mandatory component of the RACS Continuing Professional Development Program.

Australian Capital Territory Audit of Surgical Mortality (ACTASM) Report 2017

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3. AUDIT AND REPORTING PROCESS The ACTASM audits patient deaths that occur in public and private hospitals during an episode of surgical care, whether or not the patient underwent a surgical procedure. The audit includes cases in which a surgeon was involved in the management of a patient admitted by another team, and cases transferred to the surgeon’s care during the admission. When no information was provided for a question in an audit form, this has been marked in the report and the case excluded from denominator in analysis. This report covers the period 1 January 2017 to 31 December 2017, with a census date of 29 June 2018.

Surgeons are asked to report against the following criteria: • areas of consideration: where care could have been improved or different, but may be an area of debate • areas of concern: where care should have been better managed • adverse events: an unintended injury, caused by medical management rather than by disease, which is sufficiently serious to lead to prolonged hospitalisation or to temporary or permanent impairment or disability of the patient, which contributes to, or causes, death.

The audit process is outlined below: The ACTASM is notified of a death by the medical records department of a participating hospital.

1. A surgical case form is sent to the consultant surgeon for completion. This provides an opportunity for self-reflection on the case.

2. T he completed surgical case form is de-identified and sent to a different surgeon of the same specialty for peer review. This is referred to as first-line assessment. The first-line assessor may find no clinical incidents, or may find clinical incidents that do not need further assessment, and can choose to close the case at this stage. If they are unable to come to a decision based on the information available, the case is then referred for a case note review. This is referred to as second-line assessment.

3. A ll ACT second-line assessments are sent interstate to ensure objectivity. The second-line assessor reviews the case notes, identifies any clinical incidents, and provides feedback for the surgeon. Incidents are rated in relation to seriousness, preventability and outcome. The case notes and feedback are returned to the ACTASM. 4. O nce the assessment is complete and any clinical issues have been identified, the case is coded for territory and national reporting, and individualised feedback is provided to the surgeon.

5. T he audit is intended to be educational not punitive. At all times the surgeon has the right of reply. Any feedback received is reviewed by the clinical director and, where appropriate, a surgeon may appeal the outcome of the assessment and an additional second-line assessment may be performed.

The audit process is represented schematically in Figure 1.

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Royal Australasian College of Surgeons

Figure 1: Australian Capital Territory Audit of Surgical Mortality (ACTASM) methodology

ACTASM receives notification of death

Surgical case form (SCF) sent to surgeon for completion

Completed SCF returned to ACTASM and deidentified

SCF sent for first-line assessment

Second-line assessment (SLA) required?

Yes

SLA request sent

No

Feedback to surgeon

Feedback to surgeon

Yes

Has an appeal been lodged?

No

Case closed

Australian Capital Territory Audit of Surgical Mortality (ACTASM) Report 2017

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4. AUDIT PARTICIPATION All public and private hospitals in the ACT participate in ACTASM. In the period 1 January 2017 to 31 December 2017 there were three hospitals that reported deaths. The other participating hospitals had no notifications during the audit period.

Participation in ACTASM by consultant surgeons in the ACT is at 95.0% (76/80), with 75.0% (57/76) of surgeons also participating as assessors. Participation is mandatory for consultant surgeons, and unregistered surgeons are flagged when a case under their care is referred to the audit. If a surgeon has not had a mortality they may not be an active audit participant.

Participation is not mandatory for Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Fellows. Overall, 50.0% (18/36) of ACT RANZCOG Fellows participated in ACTASM. Of the participating Fellows, 72.2% (13/18) also acted as assessors.

Participation by Australian and New Zealand College of Anesthetists (ANZCA) Fellows is at 35.8% (29/81).

Of those participating, 82.8% (24/29) of Fellows also acted as assessors. Participation is not mandatory for ANZCA Fellows. Cases identified in the surgical case form as potentially having an anaesthetic component to the death are reviewed separately as part of the anaesthetic audit process. The data collected from ANZCA Fellows goes towards the Anaesthetic Triennial Report.

5. ACTIVITY This report covers the period 1 January 2017 to 31 December 2017, with a census date of 29 June 2018.

During that period 158 cases were reported to ACTASM from three hospitals. This is a 19.0% increase from 2016. Reasons for this substantial increase include a previously non-compliant private hospital becoming compliant in 2017, and audit processes being regulated to ensure that all patients who underwent an operation were captured, even those who were not under the primary case of a surgeon. When interpreting data in this report, consideration needs to be given to the small numbers which may fluctuate from year to year.

The ACTASM case status is shown in Figure 2. Of the 158 cases: • 69.0% (109/158) of cases completed the full audit process and were closed prior to the census date. These are the cases that form the basis of the analyses in this report.

• 19.6% (31/158) of cases were still in progress at the census date. This is a decrease from 2016, in which 28.1% (36/128) of cases were still in progress at the census date. The timely completion of case and assessment forms improves the validity of the audit process by ensuring that data is recorded in the correct reporting period.

• 11.4% (18/158) of cases were excluded. Cases are excluded if the patient was admitted for terminal care, was inappropriately attributed to surgery or the case was lost to follow-up. This is a decrease in the number of excluded cases from 2016, in which the exclusion rate was 16.4% (21/128). This also means that ACTASM is below the national exclusion rate of 14.7% (672/4,559).

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Royal Australasian College of Surgeons

In 2017, 12.8% (14/109) of cases underwent second-line assessment, an increase from 2016 in which 9.9% (10/101) of cases underwent second-line assessment. Nationally, 9.9% of cases underwent second-line assessment in 2017. As second-line assessments have an extended audit process it is likely that some of those cases sent for second-line assessment were still in progress at the census date and were therefore not included in this report.

Figure 2: Audit status — cases at census date per year (n=782) 180 160 140 Cases (n)

120 110

▀ Excluded ▀ In Progress ▀ Closed

80 60 40 20 0

2012

2013

2014

2015

2016

2017

Audit period (Year)

160 140

6. PATIENT PROFILE 100 Cases (n)

120

80

60 whose case had completed the audit process: Of the 109 patients 40

• 62.4% (68/109) were male, with an average age of 73 years (range, 7-99).

▀ Excluded ▀ In Progress ▀ Closed

20

• 37.6% (41/109) were female, with an average age of 75 years (range, 23-98).

Risk status:

0

2011

2012

2013

2014

2015

2016

period • 86.2% (94/109) of patients had at leastAudit one comorbidity, with 40.4% (44/109) having three or more. The most frequently occurring comorbidities were cardiovascular problems (22.9%, 56/245), advanced age (23.3%, 57/245) and respiratory disease (11.0%, 27/245).

• 68.4% (65/95; no information provided for 14 cases) of patients had an American Society of Anesthesiologists (ASA) grade of 4 or higher, indicating the presence of severe systemic disease that is a threat to life.

• Assessors considered the patient’s risk of death prior to any surgery to be considerable or expected in 59.0% (46/78) of cases. Note: this analysis only includes patients who had surgery.

Australian Capital Territory Audit of Surgical Mortality (ACTASM) Report 2017

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7. HOSPITAL CARE Figure 3 is a box-and-whisker plot in which: • the central box represents the values from the lower to upper quartile (25th to 75th percentiles) • the middle line represents the median value • the vertical line extends from the minimum value to the maximum value, excluding extreme values.

Figure 3: Length of stay per year (n=689)

Length of stay (days)

30

20

10

0 2012

2013

2014

2015

2016

2017

Audit period (year) Note: excludes extreme values.

7.1

Hospital Admission

In terms of hospital admissions: • 96.3% (103/107; no information provided for 2 cases) of patients were admitted into a public hospital.

• 96.3% (103/107; no information provided for 2 cases) were admitted as public patients.

• 86.2% (94/109) of patients were admitted as emergencies.

The average length of stay was 12 days, with a median of 6 days (see Figure 3).

7.2

Operative and Non-operative deaths

An overview of patients who underwent an operation is provided below.

• In 73.4% (80/109) of cases the patient had at least one operation. In total, 108 operations were performed on the 80 patients who had an operation.

• Of those patients who underwent an operation, 22.5% (18/80) had more than one operation.

• As shown in Figure 4, surgeons indicated that timing of surgical episodes were scheduled immediate (<2 hours) 38.1% (40/105: no information provided for 3 of the operations), emergency (<24 hours) 22.9% (24/105), elective, 21.0% (22/105) and scheduled emergency (>24 hours) 18.1% (19/105).

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Royal Australasian College of Surgeons

Figure 4: Urgency classification of operation (n=105) 45 40 35

Cases (n)

30 25 20 15 10 5 0

Immediate (<2 hours)

Emergency (<24 hours)

Scheduled emergency (>24 hours)

Elective

Urgency classification

The consultant completing the surgical case form was asked to record the seniority of the surgeon who made 30 the clinical decision to operate, as well as the seniority of the surgeon who performed the surgery.

25

Cases (n)

• Consultants operated in 61.1% (66/108) of all operations. Consultants operated in 57.5% (46/80) of initial 20 operations and 71.4% (20/28) of second and subsequent operations. In 2016 there was a notable decline in consultants operating in subsequent procedures, with 51.2% (21/41) of subsequent operations performed 15 by consultants. It appears as though the decline in 2016 was an anomaly, with the 2017 rate of consultants 10 operating in subsequent procedures comparable to that of the 2015 and earlier audit periods (in 2015, 75.0% (36/48) of subsequent operations were performed by consultants).

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• For each surgical episode there may have been more than one grade of surgeon operating. In this reporting 0 period, consultants operated in 61.1% (66/108) of operations, Immediate Emergency ScheduledSurgical Education Elective and Training Trainees operated in 20.4% (22/108) of operations, in 12.9% (14/108) of operations, and registrars (<2 hours) (<24 hours)Fellows operated emergency operated in 1.9% (2/108) of operations. (>24 hours) Unplanned treatment events:

Timing of surgical episode

• There was an unplanned return to theatre in 16.3% (13/80) of cases.

• The operation was abandoned due to finding a terminal situation in 5.8% (6/104; no information provided for 4 operations) of operations.

• Surgeons identified an anaesthetic component to the patient’s death in 3.8% (3/79; no information provided for 1 case) of cases. Since February 2014, all cases in which the surgeon identifies an anaesthetic component are sent for an anaesthetic review.

There were no operations performed in 26.6% (29/109) of audited deaths in 2017. In 58.6% (17/29) of those cases there was an active decision not to operate. Figure 5 shows the proportion of cases for which there was an active decision not to operate by audit period. Other reasons for not operating in 2017 included: rapid death 27.5%(8/29), not a surgical problem 17.2% (5/29), and refusal of treatment by the patient 6.9%(2/29). In some cases more than one reason was selected for not operating.

Australian Capital Territory Audit of Surgical Mortality (ACTASM) Report 2017

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Cases with

4 2 0 2011

2012

2013

2014

2015

2016

Audit period

Cases with decision not to operate(%)

Figure 5: Proportion of cases with active decision not to operate (n=689) 20 18 16 14 12 10 8 6 4 2 0

2012

2013

2014

2015

2016

2017

Audit period (year)

7.3 Risk Management The treating surgeon was asked to record whether deep vein thrombosis (DVT) prophylaxis was given. They were also asked to indicate whether the patient received critical care support in an intensive care unit or high dependency unit before or after surgery.

• 91.4% (96/105; no information provided for 3 cases) of patients received some form of DVT prophylaxis. Of the 9 cases involving patients who did not receive DVT prophylaxis, surgeons indicated that providing it was not appropriate in 44.4% (4/9) of cases and in 33.3% (3/9) of cases it was an active decision to withhold (no information was provided in 1 case and DVT prophylaxis was not considered in 1 case).

• 74.1% (80/108) of patients were treated in a critical care unit. The proportion of patients being treated in a critical care unit was similar to that in 2016 (72.3%, 73/101).

• Of the cases in which the patient did not receive care an intensive care unit or high dependency unit, assessors believed that 7.1% would have benefitted from receiving such care.

• Surgeons considered that fluid balance was an issue in 2.8% (3/107) of cases.

7.4 Interhospital Transfers The treating surgeon was asked to record any issues associated with the transfer of a patient into the audited hospital hospitals: • 26% (27/104) of patients were transferred to the audited hospital during their admission.

• Surgeons indicated that in 7.4% of cases there was a delay in transfer to their hospital from another site within or outside the ACT

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Royal Australasian College of Surgeons

8. OUTCOMES 8.1 Infections ACTASM collects data and monitors trends in infection, primarily to ensure that strategies are implemented to prevent and minimise infections contracted both prior to and during surgery.

In 2017, 40.2% (43/107) of patients died with a clinically significant infection. Clinically significant infections remain an ongoing issue, with 31.0% (31/100; no information provided for 1 case) of patients in 2016 reported as having a clinically significant infection. In 2017, the national percentage of patients with a clinically significant infection was 35.2% (938/2,667), indicating that this is not an issue confined to the ACT. As shown in Table 2, of those patients who died with a clinically significant infection, surgeons indicated that the types of infection in 2017 were pneumonia (46.3%; 19/41, no information provided for 2 cases), intra-abdominal sepsis (26.8%; 11/41, no information provided for 2 cases), septicaemia (14.6%; 6/41, no information provided for 2 cases) and another source (12.2%; 5/41, no information provided for 2 cases).

Table 2: Type of clinical infection reported in 2016 and 2017 (n=72) Infection type

Number of cases (proportion of infections %) 2016

2017

Pneumonia

29.0 (9/31)

46.3 (19/41)

Intra-abdominal sepsis

32.3 (10/31)

26.8 (11/41)

Septicaemia

19.4 (6/31)

14.6 (6/41)

Other source

19.4 (6/31)

12.2 (5/41)

TOTAL

100 (31/31)

100 (41/41)

For the patients with a clinically significant infection, 43.9% (18/41, no information provided for 2 cases) acquired the infection before admission while 56.1% (23/41, no information provided for 2 cases) acquired the infection during admission. Patients who acquired an infection during their admission had a mean age of 77 years, 4 years older than the overall mean age of 73 years. The proportion of infections acquired prior to and during admission in 2017 were consistent with those in 2016 (Figure 6).

Proportion of infection cases (%)

Figure 6: Proportion of infections acquired prior to or during admission, 2012 to 2017 (n=197) 90 80 70 60 50 40 30 20 10 0

â&#x2013;&#x20AC; Aquired prior â&#x2013;&#x20AC; Aquired during

2012

2013

2014

2015

2016

2017

Audit period (year)

The average length of stay for patients with infections was 10 days, compared with 12 days for all patients.

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The timing of infections acquired during admission is shown in Table 3. Surgical site infections comprised 4.5% (no information provided for 1 case) of infections acquired during admission in 2017, a decrease from 14% in 2016.

Table 3: Timing of infections acquired during admission in 2016 and 2017 Number of cases (proportion of total infections acquired during admission %)

Infection timing

2016

2017

Acquired preoperatively

14.2

36.3

Surgical site infection

14.2

4.5

Acquired postoperatively

64.3

54.5

Other invasive site infection

7.1

4.5

TOTAL

100

100

In cases in which there was a clinically significant infection, surgeons considered that the antibiotic regime was appropriate in 97.4% (38/39: no information provided for 4 cases) of cases.

8.2 Postoperative complications The treating surgeon was asked to record any complications that occurred following a surgical procedure.

Complications occurred in 36.3% (29/80) of operative cases. A total of 32 complications were recorded for the 29 cases with complications.

Treating surgeons recorded the following complications based on the list of complications provided in the surgical case form: anastomotic leak (4/32), tissue ischaemia (3/32) postoperative bleeding (2/32) and procedure-related sepsis (2/32). The largest proportion of complications were recorded as ‘other’ (65.6%, 21/32). Where more information was provided for complications recorded as ‘other’, the most frequent explanations were respiratory issues (7/32) and cardiac issues (4/32).

Postoperative complication (%)

Figure 7: Postoperative complications by admission status and audit period, 2012 to 2017 (n=456) !

100 90 80 70 60 50 40 30 20 10 0

▀ Emergency ▀ Elective

2012

2013

2014

2015

2016

2017

Audit period (year)

In 2017, a higher rate of complications was seen in elective admission patients (73.3%, 11/15) compared with emergency admission patients (27.6%, 18/65). This is consistent with previous years (see Figure 7). One possible explanation for the difference in the frequency of postoperative complications is that the emergency patients were already at risk for a bad outcome because of their comorbidities – they did not need a new event to cause their death. Elective patients were more likely to die as a consequence of a new event, which shows in the data as a specific postoperative complication.

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8.3 Causes of Death The cause of death recorded by the treating surgeon is based on the clinical course of the patient and any relevant supporting evidence from investigations. Where doubt exists around the circumstances leading to death, the case may be referred to the coroner. In other instances in which the cause of death is not clear, a postmortem examination may be requested. â&#x20AC;˘ 166 causes of death were reported in 109 patients, with surgeons reporting a maximum of 3 causes of death per patient. â&#x20AC;˘ The most commonly reported causes of death were acute respiratory/pneumonia (22.3%; 37/166), neurological problems* (18.1%; 30/166), multiple organ failure (13.3%; 22/166), sepsis (12.0%; 20/166), and cardiac causes (7.2%; 12/166). *Neurological problems include diffuse brain injury, head injury, intracerebral haemorrhage, subarachnoid haemorrhage and subdural haematoma.

9. CLINICAL MANAGEMENT ISSUES A primary objective of the peer-review process is to determine whether death was a direct result of the disease process alone, or if aspects of patient management might have contributed to that outcome.

There are two possible outcomes for the peer-review process. The first is that the death of the patient was a direct outcome of the disease process, with clinical management having no impact on the outcome. The second is a perception that aspects of patient management may have contributed to the death of the patient.

If there was a perception that the clinical management may have contributed to death, the clinical incidents were reported as adverse events, areas of concern or areas of consideration. Refer to Section 3 for criteria definitions.

Assessors did not identify any CMI in 75.7% (81/107, no information provided for 2 cases) of cases. When combined with cases reported to only have areas of consideration (14.0% of cases, 15/107), the total number of cases with no or minor criticism was 89.7% (96/107).

Cases can be identified as having one or more clinical management issues. CMI were reported in 24.3% (26/107) of cases. A total of 36 CMI were identified, with up to 3 issues reported for 3 cases. The proportion of cases with identified CMI has increased since 2016 when the proportion was 17.8% (18/101).

The identification by an assessor of an area of concern or adverse event denotes a greater degree of criticism and indicates a serious CMI. In 2017, serious CMI occurred in 10.3% (11/107) of cases. This is higher than the percentage of cases in which adverse events or areas of concern were reported nationally in 2017 (8.2%, 219/2,677) and within the ACT in 2016 (6.9%, 7/101). Figure 8 shows trends in serious CMI within the ACT.

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14 12 10 8 6 4 2 0

2012

2013

2014

2015

2016

2017

Audit period (year)

In terms of preventability and attribution: â&#x20AC;˘ 22.2% (8/36) of issues were considered definitely preventable, while 44.4% (16/36) were considered probably preventable. In 2016, 7.7% (2/26) and 38.5% (10/26) of issues were considered definitely or possibly preventable respectively, highlighting a notable increase in preventable CMIs within the ACT for 2017. â&#x20AC;˘ 52.7% (19/36) of issues were associated with the audited surgical team, 38.9% (14/36) with another clinical team, and 5.6% (2/36) with other factors, such as the underlying disease process.

As shown in Figure 9, the areas of care most frequently identified by assessors as requiring improvement were postoperative care (11.4%, 12/105; no information provided for 2 cases), decision to operate (11.3%, 12/106; no information provided for 1 case) and preoperative management (11.2%, 12/107). Assessors were generally happy with the grade of surgeon operating, indicating that there could have been improvement in this area in only 2 cases (1.9%, 2/107; no information provided for 1 case).

Figure 9: Areas identified by assessors for management improvement (n=107) 12

Cases (%)

10 8 6 4 2 0

Operation Postoperative Preoperative Decision to timing care management operate

Choice of Intraoperative Grade of operation care surgeon operating

Clinical management issues

Serious clinical management issues had a higher prevalence in elective patients (26.7%, 4/15) compared with patients admitted as emergencies (7.6%, 7/92). As seen in Figure 10, this disparity has been consistent across audit periods.

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Royal Australasian College of Surgeons

Proportion of cases with serious CMI (%)

Proportion of cases with serious CMI (%)

Figure 8: Cases with one or more serious clinical management issue (CMI), by audit period, 2012 to 2017 (n=601)

Cases with serious CMI (%)

Figure 10: Cases with serious clinical management issue (CMI) by admission type, 2012 to 2017 (n=595) 50 45 40 35 30 25 20 15 10 5 0

â&#x2013;&#x20AC; Emergency â&#x2013;&#x20AC; Elective

2012

2013

2014

2015

2016

2017

Audit period (year)

10. FINAL SUMMARY This is the seventh full year of reporting for the ACTASM, and the project is now well embedded in the ACT. As the audit progresses in the ACT over the years, emerging trends across the territory can be identified. The feedback provided through these reports, as well as through the hospital governance reports, can help drive system improvements, potentially leading to better outcomes for all surgical patients. Longevity of the audit process has been shown to correlate with a reduction in surgical deaths, with the Western Australian Audit of Surgical Mortality associated with a 30% reduction in surgical deaths over a 10 year audit period2.

The use of interstate assessors in the ACT safeguards the independent peer-review process and ensures that second-line cases remain de-identified. This is of particular importance when there are very small numbers of surgeons in a particular specialty or subspecialty. As of 2017, first-line assessments for smaller specialties are also assessed interstate.

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11. ACKNOWLEDGMENTS The ACTASM acknowledges the support and assistance of many individuals and institutions that have helped in the continuation and development of this project, including: • all participating surgeons • all first-line assessors • all second-line assessors • medical records, safety and quality and risk management departments in all participating hospitals • the ACT Government Health Directorate for funding and ongoing support • the state and territory project managers and officers • the RACS Division of Research, Audit & Academic Surgery staff, particularly: Professor Guy Maddern

Chair, ANZASM Steering Committee, Surgical Director of Research and Evaluation

A/Professor Wendy Babidge

General Manager, Research, Audit & Academic Surgery

Dr Helena Kopunic

Surgical Audits Manager

Ms Angie Clerc-Hawke

Project Manager, ACTASM

Mr Dylan Hansen

Data Analyst/Research Assistant, ANZASM

ACTASM MANAGEMENT COMMITTEE MEMBERSHIP Dr John Tharion

Clinical Director, ACTASM, Australasian Society of Cardiac & Thoracic Surgeons

Dr Alexander Burns

Australian Orthopaedic Association

Dr Phillip Jeans

General Surgeons Australia

Dr Fardin Eghtederi

Australian & New Zealand Society of Otolaryngology Head & Neck Surgery

Dr David McDowell

Neurosurgical Society of Australasia

Dr David Hardman

Vascular surgeon

Dr Stephen Robson

RANZCOG

Dr Carmel McInerney

ANZCA

A/Professor Andrew Mitchell

ACT Government, Health Directorate Representative

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Royal Australasian College of Surgeons

12. REFERENCES 1. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2017. This document was released in November 2017 2. Azzam DG, Neo CA, Itotoh FE, Aitken RJ. The Western Australian Audit of Surgical Mortality: outcomes from the first 10 years; MJ Aust 2013 [cited 2016 Aug];199(8):539-542. Available from: https://www.mja.com.au/ journal/2013/199/8/western-australian-audit-surgical-mortality-outcomes-first-10-years DOI: 10.5694/ mja13.10256

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Contact Royal Australasian College of Surgeons Australian Capital Territory Audit of Surgical Mortality (ACTASM) Suite 31, 2 King Street Deakin, ACT 2600 Australia Telephone: +61 2 6285 4558 Facsimile:

+61 2 6285 3366

Email: actasm@surgeons.org Website: www.surgeons.org/actasm The information contained in this report has been prepared under the auspices of the Royal Australasian College of Surgeons, Australian Capital Territory Audit of Surgical Mortality Management Committee, which is a declared quality assurance committee under the Health Act 1993.

The information contained in this report has been prepared by the Royal Australasian College of Surgeons, Australian Capital Territory Audit of Surgical Mortality Management Committee. The Australian and New Zealand Audit of Surgical Mortality, including the Australian Capital Territory Audit of Surgical Mortality, has protection under the Commonwealth Qualified Privilege Scheme under Part VC of the Health Insurance Act 1973 (Gazetted 25 July 2016)