NTASM 2023 ANNUAL REPORT by maxgecko

Northern Territory Audit of Surgical Mortality (NTASM) 2023 ANNUAL REPORT 5-year update, 1 July 2018 – 30 June 2023

Contact Royal Australasian College of Surgeons Northern Territory Audit of Surgical Mortality PO Box 7385 East Brisbane Qld 4169 Australia Telephone: Facsimile: Email: Website:

61 7 3249 2971 61 7 3391 7915 NTASM@surgeons.org https://www.surgeons.org/en/research-audit/surgical-mortality-audits/regional-audits/ntasm

The information contained in this annual report has been prepared by the Royal Australasian College of Surgeons Northern Territory Audit of Surgical Mortality management committee. The Northern Territory Audit of Surgical Mortality is a declared quality improvement committee under Section 7 (1) of the Health Services (Quality Improvement) Act 1994 (gazetted 26 July 2005). The Australian and New Zealand Audit of Surgical Mortality, including the Northern Territory Audit of Surgical Mortality, also has protection under the Commonwealth Qualified Privilege Scheme, Part VC of the Health Insurance Act 1973 (gazetted 24 April 2022). Published: 2024

CONTENTS Clinical Director’s Report Management Committee Chair’s report Abbreviations Acknowledgements Executive summary NTASM 2018-2023 snapshot Recommendations Adopted recommendations

5 6 7 8 10 12 14 15

1. Introduction 1.1 Background 1.2 Objectives

16 16 16

2. Methods 2.1 Structure and governance 2.2 Methodology 2.3 Audit process 2.4 Surgeon assessors 2.5 Obstetrician and gynaecologist assessors 2.6 Anaesthetist assessors 2.7 Providing feedback 2.8 Data analysis/reporting conventions 2.9 Data management, storage and analysis 2.10 Statistical analysis

17 17 17 17 17 18 18 18 19 19 19

3. Results 3.1 Audit participation 3.2 Demographic profile of audited cases 3.3 Risk management strategies 3.4 Profile of operative intervention 3.5 Infections 3.6 Trauma

20 20 23 25 26 32 33

4. Peer-review outcomes 4.1 Second-line assessments 4.2 Deep vein thrombosis prophylaxis 4.3 Use of ICU/critical care units 4.4 Clinical management issues

34 34 34 35 35

5. Aboriginal and Torres Strait Islander patients 5.1 Overview 5.2 Age 5.3 Comorbidities 5.4 Operations 5.5 Peer-review outcomes

37 37 39 40 41 41

6. NT baseline patients 2022 6.1 Characteristics of NT baseline and NTASM patients 6.2 Comorbidities 6.3 Age

42 42 44 45

7. References

8. Appendices 8.1 Appendix A: NTASM governance structure 8.2 Appendix B: NTASM audit process 8.3 Appendix C: Surgeons report what they would have done differently 8.4 Appendix D: Data definitions 8.5 Appendix E: Performance review data

47 47 48 49 51 52

FIGURES

Figure 1: Age distribution of NTASM patients, 2018–2023

Figure 2: Types of comorbidities, 2018–2023

Figure 3: Delays in surgical diagnoses for NTASM patients who had an operation, 2018–2023

Figure 4: ASA class for NTASM patients who had an operation, 2018–2023

Figure 5: Surgeon-assessed risk of death for operative patients, 2018–2023

Figure 6: Operations conducted with a consultant surgeon present in theatre, 2018–2023

Figure 7: NTASM patients with postoperative complications, 2018–2023

Figure 8: Assessor-perceived appropriateness of DVT prophylaxis by year, 2018–2023

Figure 9: Median age of NTASM Aboriginal and Torres Strait Islander and non-Indigenous patients by year and gender, 2018–2023

Figure 10: NT baseline and NTASM patients by age group, January to December 2022

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

TABLES Table 1:

NTASM comparison, 2018–2023 audit period

Table 2:

NTASM cases at census date, 2018–2023

Table 3:

Participating NT surgeons by surgical specialty, as of October 2023

Table 4:

Number of communication issues reported by treating surgeons

Table 5:

Audited deaths with transfer inter-hospitals and delay in transfer, 2018–2023

Table 6:

Types of DVT prophylaxis provided to NTASM patients, 2018–2023

Table 7:

Most frequently performed operations, 2018–2023

Table 8:

Unplanned return to theatre, 2018–2023

Table 9: Infection type in NTASM patients who acquired a clinically significant infection during admission, 2018–2023

Table 10: Most frequently identified infective bacteria, viruses and yeasts in NTASM patients, 2018–2023

Table 11: Patient location at time of trauma-causing fall, 2018–2023

Table 12: Audited deaths without use of ICU/CCU, 2018–2023

Table 13: Impact of CMI according to assessor and most frequent issue, 2018–2023

Table 14: Characteristics and clinical outcomes of NTASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients, 2018–2023

Table 15: Most frequent comorbidities in NTASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients, 2018–2023

Table 16: Distribution of NTASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients admitted by surgical specialty and percentage who had an operation, 2018–2023

Table 17: Assessor-perceived difference in care provided to NTASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients who had an operation, 2018–2023

Table 18: Characteristics of NT baseline and NTASM patients, January to December 2022

Table 19: Comorbidity frequency in NT baseline and NTASM patients, January to December 2022

NTASM REPORT (2023)

DATA FIGURES Data figure 1: NTASM governance structure

Data figure 2: NTASM audit process

DATA TABLES

Data table 1: Status of all NTASM cases at time of census, 2018–2023

Data table 2: Notifications of surgical deaths reviewed by NTASM by year, 2018–2023

Data table 3: Sex ratio of NTASM patients by year, 2018–2023

Data table 4: Age distribution of NTASM patients, 2018–2023

Data table 5: Age of NTASM patients in 5-year age groups, 2018–2023

Data table 6: Most frequent comorbidities in NTASM patients, 2018–2023

Data table 7: Delays in surgical diagnoses for NTASM patients who had an operation, 2018–2023

Data table 8: ASA class for NTASM patients who had an operation, 2018–2023

Data table 9: Surgeon-assessed risk of death for operative patients, 2018–2023

Data table 10: Consultant surgeon presence in theatre, 2018–2023

Data table 11: NTASM postoperative complications by year, 2018–2023

Data table 12: Postoperative complications in NTASM patients, 2018–2023

Data table 13: Type of road traffic incidents that caused trauma, 2018–2023

Data table 14: Assessor-perceived appropriateness of DVT prophylaxis per year, 2018–2023

Data table 15: Median age of NTASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients by year and sex, 2018–2023

Data table 16: Age of baseline and NTASM patients in 5-year age groups, January to December 2022

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

CLINICAL DIRECTOR’S REPORT I believe you will find this Northern Territory Audit of Surgical Mortality (NTASM) annual report (2018–2023) of value, regardless of your healthcare sector. The NTASM data demonstrate that adverse events in NTASM surgical patients who died have been minimal; the presence of consultant surgeons (in any capacity) in theatre is high; distance and delay in the Northern Territory (NT) is an issue; there is a large age gap between Aboriginal and Torres Strait Islander patients and non-Indigenous patients; and in the NT the surgeon-to-patient ratio remains the lowest in Australia. The NT is geographically large, with few hospitals and many patients and communities. Support for rural and regional surgeons needs to be considered by the Royal Australasian College of Surgeons (RACS) and the NT Government. There is a need to improve staffing and retain surgeons and healthcare workers in the NT. I suggest creative marketing and incentives to encourage interstate support and attract new Fellows to the NT. NTASM and the Australian and New Zealand Audit of Surgical Mortality (ANZASM) have made significant changes to improve data collection and enhance data security. NTASM is focused on timely reporting and feedback. This can occur when surgeons improve the return time of their NTASM forms. Second-line assessments can be completed online, which improves timely feedback to treating surgeons. The NTASM staff and I review the Surgeon-completed Preventable Clinical Management Issue (PCMI) forms. The audit loop is effectively and efficiently closed when these forms are returned. I encourage surgeons to complete these forms. For security reasons, feedback is now only available via NTASM online. In 2022/2023, surgeons downloaded 54% of their feedback. I encourage surgeons to review all of their feedback. I trust that 2024 will see significant improvement in surgical care delivery across the NT and that surgeons will value all feedback received from NTASM. The NTASM seminar Futile Care at the tri-state meeting in Darwin (2023) was worthwhile, with both interstate and local speakers. My sincere thanks to all speakers and attendees. Thank you to the NT Government for its valuable support and continued funding of NTASM. A special thanks must go to the NT surgeons who deliver surgical care to patients across the Territory, the NT data custodians, and the NTASM data managers and staff.

Dr John North NTASM Clinical Director

NTASM REPORT (2023)

MANAGEMENT COMMITTEE CHAIR’S REPORT In regard to surgical services provision in the Northern Territory (NT), 2023 continues to be a challenging year. Staff shortages on many levels from junior staff to consultants results in significant overtime. This has an impact on work satisfaction and work–life balance and increases risk of burnout. Anaesthetist and nursing shortages led to theatre cancellations and further worsened the already overwhelming theatre waitlists; however, some aspects are expected to improve. The anaesthetist numbers are expected to normalise in 2024 and therefore theatre access will be back to normal for surgeons. Royal Darwin Hospital hired a young general surgeon with thoracic surgery interest at the beginning of 2023. Another surgeon also offered to take up thoracic surgery as a subspecialty of interest. The services were transformed from a single-centre external service to dual-centre external service with significant coordination from the local general surgeons with thoracic surgery interest. The changes kicked off at the beginning of 2023 and have proven to be successful. This current model is expected to pave the way to a future local thoracic surgery service with external support. Despite these challenges, the NTASM 2023 report shows encouraging data. We continue to do well with significant consultant presence in theatre, reducing unplanned return to theatre, significant use of deep vein thrombosis prophylaxis and, most importantly, reducing areas of concern or clinical issues. Areas that we could improve on include delay in transfers and incidence of clinically significant infections. We are thankful to the NT Government for their ongoing support of NTASM that makes the whole audit process possible. A sincere thanks to the Dr John North (Clinical Director of NTASM) and the team of staff who collected the data and prepared the report. We are hopeful that 2024 will be a better year with better staffing and theatre access that will enable us to service the healthcare needs of the Territorians.

Dr Manimaran Sinnathamby Director of General Surgery Consultant General and Breast Surgeon Royal Darwin Hospital

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

ABBREVIATIONS ACTASM

Australian Capital Territory Audit of Surgical Mortality

AIHW

Australian Institute of Health and Welfare

ANZASM

Australian and New Zealand Audit of Surgical Mortality

ANZCA

Australian and New Zealand College of Anaesthetists

Ahpra

Australian Health Practitioner Regulation Agency

ASA

American Society of Anesthesiologists

confidence interval

computed tomography

CMI

clinical management issue

CVD

cardiovascular disease

DVT

deep vein thrombosis

ECOG

Eastern Cooperative Oncology Group performance score

EVD

external ventricular drain

EMR

electronic medical records

ERCP

endoscopic retrograde cholangiopancreatography

FLA

first-line assessment

general practitioner

HDU

high dependency unit

ICD-10

International Classification of Diseases 10th revision

ICU

intensive care unit

IQR

interquartile range

LRINEC

laboratory risk indicator for necrotizing fasciitis

Northern Territory

NTASM

Northern Territory Audit of Surgical Mortality

QASM

Queensland Audit of Surgical Mortality

QLD

Queensland

risk ratio

RACS

Royal Australasian College of Surgeons

RANZCOG

Royal Australian and New Zealand College of Obstetricians and Gynaecologists

SCF

surgical case form

SLA

second-line assessment

SST

Safer Surgical Teamwork

TASM

Tasmanian Audit of Surgical Mortality

TED

thromboembolic deterrent

NTASM REPORT (2023)

ACKNOWLEDGEMENTS We thank the following individuals and organisations for their contribution to NTASM: NT Government for funding NTASM Assessors for diligently completing their assessments Chair, Dr Manimaran Sinnathamby, for his leadership and support NTASM management committee for its wisdom and counsel NTASM staff for systematically managing the process RACS professional development department for facilitating the SST workshops.

NTASM MANAGEMENT COMMITTEE MEMBERS

Dr Manimaran Sinnathamby, Chair, NTASM Steering Committee, RACS Dr Peter Cosman, Director of Surgical Services, Top End Health Service Dr Suresh Mahendran, otolaryngology surgeon, Royal Darwin Hospital Dr Mark Hamilton, Head, Department of Vascular Surgery, Top End Health Service/Central Australia Health Service Dr Kanishka Williams, orthopaedic surgeon, Alice Springs Hospital Dr John North, Clinical Director, NTASM, RACS

NT DEPARTMENT OF HEALTH REPRESENTATIVE

Dr Sara Watson, Executive Director of Medical Services, Royal Darwin Hospital

ANAESTHESIA REPRESENTATIVE

Dr Phil Blum, Deputy Director, Department of Anaesthesia, Top End Health Service, and NT representative, ANZCA Mortality Subcommittee

OBSTETRICS AND GYNAECOLOGY REPRESENTATIVE Dr Michelle Harris, RANZCOG representative

ANZASM STAFF

Professor Guy Maddern, Chair, ANZASM Steering Committee, RACS Professor Wendy Babidge, General Manager, Research Audit and Academic Surgery, RACS Dr Helena Kopunic, Surgical Audit Manager, Research Audit and Academic Surgery, RACS

NTASM STAFF

Dr John North, Clinical Director Dr Jenny Allen, Project Manager Sidara Engelhardt, Project Officer Chloe Cao, Research Data Officer Kyrsty Webb, Administration Officer

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

NTASM SUPPORT STAFF

Sonya Faint, Senior Project Officer, Queensland Audit of Surgical Mortality Trudy Dugan, Surgical Audit Officer, Royal Darwin Hospital Helen Humphreys, Health Information Manager, Darwin Private Hospital Susan Sullivan, Data Integrity Officer, Alice Springs Hospital

STATISTICIAN

Professor Robert S Ware, School of Medicine and Dentistry, Griffith University

NT GOVERNMENT DEPARTMENT OF CORPORATE AND DIGITAL DEVELOPMENT DATA SERVICES, HEALTH REPORTING AND ANALYTICS TEAM Senior Data Analyst, Peta Archer Data Analyst, Kerry Gregory Data Analyst, Ken Lin Report Developer, Kanchana Gunathilaka

NTASM REPORT (2023)

EXECUTIVE SUMMARY Overview

The Northern Territory Audit of Surgical Mortality (NTASM) is an external, independent, peer-reviewed audit of care processes associated with surgical deaths in the Northern Territory (NT). NTASM has qualified privilege protection under Commonwealth legislation (gazetted 24 April 2022). The purpose of NTASM is to provide feedback to inform, educate, facilitate change and improve practice. Surgeons are encouraged to use NTASM feedback to self-reflect and improve their practice. Hospitals and policy makers are encouraged to use NTASM feedback to develop strategies to address clinical management areas requiring improvement and to address and fill staffing gaps in the NT surgical workforce.

Northern Territory baseline data (1 January to 31 December 2022)

In Section 6 of this report, NT baseline data (all patients admitted to NT public hospitals who had an operation or surgical procedure performed by a surgeon) are compared with NTASM data (in-hospital surgical deaths where a surgeon was responsible for, or had significant involvement in, a patient’s care, regardless of whether an operation was performed or not). NT baseline data are provided by the NT Department of Corporate and Digital Development’s, Data Services, Health Reporting and Analytics Team (approval number DMSR 13143). This report covers the period 1 July 2018 to 30 June 2023 (census date 1 October 2023). Each year is from 1 July to 30 June.

Patients

81.5% (334/410) of cases were reviewed cardiovascular disease (67.1%; 194/289) was the most frequent comorbidity 81.3% (269/331) of patients had deep vein thrombosis (DVT) prophylaxis

Operations

81.1% (271/334) of patients had an operation

Postoperative complications

21.9% (59/269) of patients had a postoperative complication

Intensive care unit use

17.7% (48/271) of patients had an unplanned postoperative admission to ICU

Infections

38.0% (126/332) of patients had an infection present at the time of death 56.8% (71/125) of patients acquired the infection before admission

Traumas

most frequent traumas were falls (56.8%; 42/74), road traffic incidents (21.6%; 16/74) or violence (16.2%; 12/74)

Clinical management issues

assessors considered that 13.8% (46/334) of patients had a clinical management issue (CMI) 63.0% (29/46) of CMIs were considered preventable

Aboriginal and Torres Strait Islander patients comprised 36.2% (121/334) of NTASM surgical deaths

had a median age of 56 years (interquartile range 46–66) Note: assessors considered that 14.0% (17/121) of Aboriginal and Torres Strait Islander patients had a CMI

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

Comparison of audit data across the 5-year audit period Table 1: NTASM comparison, 2018–2023 audit period 2018–2019 n = 95

2019–2020 n = 76

2020–2021 n = 65

2021–2022 n = 91

2022–2023 n = 83

Excluded cases

Pending cases

Reviewed cases

Male

73 (IQR 57–78)

68 (IQR 53–79)

74.5 (IQR 62–78)

69 (IQR 59–78)

74 (IQR 49–86)

Female

63 (IQR 53–74)

59 (IQR 53–70)

59 (IQR 50–67)

62 (IQR 47–79)

68 (IQR 64–73)

Male

59.6%

53.0%

61.8%

62.8%

54.3%

Female

40.4%

47.0%

38.2%

37.2%

45.7%

Emergency

91.0%

87.9%

89.1%

93.6%

95.7%

Elective

9.0%

12.1%

10.9%

6.4%

4.3%

Patients transferred

28.6%

18.2%

14.5%

14.3%

19.6%

Delays in transfers

9.5%

18.2%

25.0%

18.2%

22.2%

Patients admitted with one or more comorbidities

86.5%

74.2%

92.7%

91.0%

89.1%

Patients who had at least one operation

82.0%

80.3%

85.5%

79.5%

78.3%

Patients with ASA class >3

69.7%

62.3%

78.2%

77.9%

78.3%

Cases with a considerable or expected risk of death (surgeon-identified)

63.0%

61.5%

68.1%

71.0%

62.9%

Patients with unplanned return to theatre

13.5%

22.7%

20.0%

16.7%

8.7%

Patients with anaestheticrelated issues

1.4%

5.7%

2.1%

4.8%

5.7%

Patients with postoperative complications

24.7%

23.1%

23.4%

19.4%

17.1%

DVT prophylaxis use considered inappropriate (assessor-identified)

0.0%

3.1%

0.0%

2.6%

4.3%

Fluid balance issues (assessor-identified)

5.7%

4.6%

7.3%

12.8%

2.2%

Clinically significant infections

32.6%

36.4%

47.3%

32.9%

47.8%

Second-line assessments

9.0%

7.6%

14.5%

14.1%

4.3%

Areas of concern and adverse events

5.6%

7.6%

7.3%

7.7%

2.2%

Area of NTASM comparison

Median age (years) Sex

Admission

IQR: Interquartile range; ASA: American Society of Anesthesiologists physical status classification system; DVT: deep vein thrombosis; NTASM: Northern Territory Audit of Surgical Mortality

NTASM REPORT (2023)

NTASM 2018-2023 SNAPSHOT This summary reports on cases from 1 July 2018 to 30 June 2023.

Note: Submission of incomplete data means denominators throughout this report occasionally differ.

Audit numbers

10.5%

410

Reported cases meeting NTASM criteria

Excluded terminal care cases (43/410)

81.5%

54.3%

Completed cases (334/410)

Audit feedback downloaded by surgeons in 2022-2023 (25/46)

Risk profile

Overall median age (years) (IQR 54-78)

58.7%

Male (196/334)

87.1%

Comorbidities present (291/334)

81.3%

DVT prophylaxis use (269/331)

41.3%

91.3%

Female (138/334)

Emergency (305/334)

8.7%

Elective (29/334)

67.1%

Cardiovascular disease (194/289)

68.9%

CCU use (230/334)

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

Operations

81.1%

59.1%

Patients who had an operation (271/334)

19.9%

Operations performed by consultant surgeon (275/465)

21.9%

Unplanned returns to theatre (54/271)

Postoperative complications (59/269)

Infections

38.0%

Patients with clinically significant infection (126/332)

56.8%

43.2%

Patients with clinically significant infection – before admission (71/125)

55.6%

Patients with clinically significant infection – during admission (54/125)

Pneumonia - during admission (30/54)

25.9%

Intra-abdominal sepsis - during admission (14/54)

9.3%

Septicaemia - during admission (5/54)

Aboriginal & Torres Strait Islander patients

86.8%

Median age (years) (IQR 46-66)

Comorbidities (105/121)

88.4%

Patients who had an operation (107/121)

Patients with clinically significant infection:

42.1% (51/121)

before admission: 68.6% (35/51)

14.0%

Patients with one or more clinical management issues (17/121)

Peer-review outcomes

13.8%

Patients with one or more clinical management issue (46/334)

NTASM REPORT (2023)

Number of clinical management issues (in 46 patients)

2.4%

Adverse events (8/334)

1.2%

Adverse events that caused death (4/334)

0.6%

Definitely preventable adverse events that caused death (2/334)

RECOMMENDATIONS The following recommendations are derived from responses documented in this report and trends identified in previous NTASM reports. NTASM encourages stakeholders (surgeons and hospitals) and policymakers to consider these recommendations and to advocate for improvements in surgical patient care in the NT.

1. Surgical workforce sustainability and networking across jurisdictions NT Department of Health to continue to recruit and retain surgeons in the NT In the annual reports for 2020, 2021 and 2022, NTASM highlighted that the surgical workforce to patient ratio in the NT is below that of all other Australian regions. This report again highlights that NT has only one vascular surgeon, one urology surgeon and one neurosurgeon working in the public system. Surgeon fatigue can lead to burn-out and poor patient outcomes. Long and complex operations may not be performed because more than one surgeon is required in theatre.

RACS to strengthen communication with NT Department of Health and streamline surgical training RACS is encouraged to continue working with the NT Department of Health to strengthen the rural surgical workforce. RACS will review its Specialist International Medical Graduate program to assist rural regions to employ international graduates.

NTASM to facilitate surgeons networking across jurisdictions NTASM continues to encourage and sponsor a NT surgeon to attend the Queensland Audit of Surgical Mortality (QASM) annual seminar and to host NTASM seminars. Prior to the start of the RACS Tri-state Annual Scientific Meeting (WA, SA and NT) in August 2023, NTASM hosted the free seminar Futile Care. Three interstate surgeons presented together with an NT surgeon and a NT palliative care physician (available on the NTASM website).

2. Chronic disease and infection prevention education NT Department of Health to continue public education around chronic disease and prevention Chronic diseases, including cardiovascular disease (CVD) and diabetes, continue to be highlighted in this report for all patients. CVD was present in more than half of all NTASM patients (62.8% of Aboriginal and Torres Strait Islander patients and 54.9% of non-Indigenous patients). Diabetes and renal disease were present in half of Aboriginal and Torres Strait Islander patients (49.6% and 56.2%, respectively). Aboriginal and Torres Strait Islander patients continue to present to hospital with more infections already present (28.9%) than non-Indigenous patients have (17.1%).

3. Health promotion for Aboriginal and Torres Strait Islander people NT Department of Health to continue health education in rural and remote communities NTASM consistently reports that, on average, Aboriginal and Torres Strait Islander surgical patients die at a younger age than non-Indigenous patients. In this report, the average age gap is 18 years.

4. NTASM processes and systems refinement NTASM and ANZASM to continue to refine and streamline process NTASM to develop a form to streamline data collection for anaesthetic cases (implementation in 2024). NTASM to increase communication with surgeons to reduce the median length of time to return SCFs from 60.9 days (IQR 21.2–132.3) to less than 28 days. NTASM to collate and report on surgeon feedback provided on Preventable Clinical Management Issue (PCMI) forms. The Australian and New Zealand Audit of Surgical Mortality (ANZASM) to consider including continuing professional development (CPD) points for reading the National Case Note Review Booklet and Case of the Month.

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

ADOPTED RECOMMENDATIONS 1. NTASM processes streamlined

NTASM continues to use secure file transfer systems for notifications of deaths and medical records. This process will be extended to the anaesthetic review process. NTASM continues to encourage locum surgeons to access medical records via the secure file transfer system to complete SCFs. Monitoring the number of cases that surgeons have accessed and from which they have downloaded their feedback has assisted NTASM in ‘closing-the-loop’ regarding learning from the audit. NT surgeons have downloaded 54.3% (25/46) of feedback since July 2022.

2. ANZASM process streamlined

ANZASM has amended data collection fields in the surgical case form (SCF). Testing of the SCF amendments is complete, ready for deployment in 2024. These amendments include data entries for alcohol and smoking as cofactors, and fluid balance issues as either overload, dehydration or both. ANZASM has amended a data collection field in both the first- and second-line assessment forms. These forms now include a question if the death was considered to be preventable. ANZASM has made data fields mandatory to improve the accuracy of data collection. ANZASM implemented the online second-line assessment process in November 2023. ANZASM received CPD approval for returned PCMI feedback forms. Surgeons receive one CPD point for each completed form returned. NT surgeons have received 22 feedback forms.

3. ANZASM and CPD Homes

CPD Homes are the educational providers that deliver CPD programs and make sure doctors registered in their CPD home meet their minimum CPD requirements. ANZASM is approved by the Australian Health Practitioner Regulation Agency (Ahpra) as a surgical high-level requirement for CPD homes. All surgeons will have to participate and complete ANZASM documents regardless of the surgeon’s preferred CPD Home.

NTASM REPORT (2023)

INTRODUCTION

KEY POINTS NTASM is an external, surgeon-led, peer-reviewed audit of patient deaths under surgical care. This report is a review of all surgical deaths notified during the period 1 July 2018 to 30 June 2023. This report comprises a comparative analysis of the 334 cases that completed the full peer-review process.

1.1

Background

Surgery in the Northern Territory (NT) is safe and well-regulated. Only a small proportion of surgical patients die, and those deaths are reviewed by consultant surgeons and peer surgeon assessors. The Royal Australasian College of Surgeons (RACS) facilitates this review process via the Northern Territory Audit of Surgical Mortality (NTASM). NTASM was established in 2010 and is government-funded by the NT Department of Health. NTASM is an external, surgeon-led, peer-reviewed audit of processes of care associated with surgery-related deaths in the NT. It is designed as a feedback mechanism to encourage participating surgeons to reflect on surgical care and practice following the death of a patient. Information submitted to NTASM by the treating surgeon provides an opportunity to identify areas where care could be improved. Surgical peers review and assess the clinical management of each patient (including hospital systems and processes) and provide feedback to the treating surgeon. The deidentified and aggregated results of these reviews are presented in this document. NTASM provides feedback as follows:

Surgeons receive assessor feedback of each case, which can be securely downloaded. Surgeons receive an electronic copy of the NTASM annual report, which is also posted on the RACS website. urgeons receive deidentified summaries of assessments in the National Case Note Review Booklet, which presents S cases from across Australia. Surgeons receive a monthly deidentified summary of a case assessment in the Case of the Month. Participating hospitals receive reports of aggregated, deidentified data comparing similar hospitals across Australia. urgeons can access their own audit data via NTASM online. Each self-assessment and peer-review assessment in the S NTASM database provides valuable insight into current practice and opportunities for practice improvement. Ongoing refinements to NTASM processes enhance the quality and reliability of the data captured. This report covers surgery-related deaths from 1 July 2018 to 30 June 2023 (census date 1 October 2023). Data analysis relates to the date of death rather than the date of notification to NTASM. Some patient cases reported during this period will still be undergoing review at the census date. These cases will be included in the next NTASM report. Submission of incomplete data means denominators throughout this report occasionally differ.

1.2

Objectives

The objectives of the audit are to:

encourage and support surgeons to self-appraise their clinical care management encourage and support surgeons to appraise the clinical care management of their peers inform, educate, facilitate change and improve practice by providing feedback on surgical deaths in the NT.

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

METHODS

2.1

Structure and governance

NTASM is overseen by the Australian and New Zealand Audit of Surgical Mortality (ANZASM). ANZASM is managed by Research, Audit and Academic Surgery within the Fellowship Engagement portfolio of RACS. Surgeon participation in NTASM is mandated as part of the RACS continuing professional development (CPD) program (since January 2010). The NTASM governance structure is illustrated in Section 8.1. NTASM is a declared quality assurance committee under Section 7 (1) of the Health Services (Quality Improvement) Act 1994 (gazetted 26 July 2005). ANZASM, including NTASM, has protection under the Commonwealth Qualified Privilege Scheme under Part VC of the Health Insurance Act 1973 (gazetted 24 April 2022).

2.2

Methodology

NTASM 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 deaths that occur in NT hospitals while a patient is under the care of a surgeon. NTASM includes all patient deaths that meet one of the following criteria:

The patient was under the care of a surgeon (surgical admission) and may not have had an operation. The patient was under the care of a physician (medical admission) and subsequently had an operation. he patient’s death was possibly or definitely related to anaesthesia during surgery or occurred within 48 hours of T surgery. The patient was a gynaecology-related case and had an operation. NTASM excludes all patient deaths whereby the patient was deemed terminal upon admission and did not have an operation. Admission for terminal care and having no care is not the same as being admitted and having capped care. Many patients are offered a period of active treatment on the basis that their care will not be escalated to include an operation. During this time, they might be admitted to the intensive care unit (ICU) and/or receive other interventions (e.g. dialysis, diagnostic scans, interventional radiology). These patients were not admitted for terminal care but for active capped care.

2.3

Audit process

The audit process combines surgeon self-refection with peer review of all surgical deaths in the NT to determine whether the death was a direct result of the disease process alone or whether 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 audit process begins when a surgical or medical records department in an NT hospital notifies NTASM staff of a surgical death, or when a surgeon self-reports a surgical death. The overall audit process is coordinated by NTASM staff, as outlined in Section 8.2.

2.4

Surgeon assessors

Surgeons participate in the audit in the following capacities:

as a surgeon who self-assesses the clinical management provided to a patient under review as a peer assessor who conducts a first-line (FLA) or second-line assessment (SLA). First- and second-line assessors are surgical peers, sometimes appointed from a different Australian state or territory to the NT 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 NTASM 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).

NTASM REPORT (2023)

Surgeons and assessors provide clinical judgement on one of the two possible outcomes: 1. The patient’s death was a direct result 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. In the case of the latter, surgeons and assessors may identify CMIs, which are classified as follows:

rea of consideration: the assessor believes an area of care could have been improved or different but recognises a there may be debate about this area of concern: the assessor believes that an area of care should have been better dverse event: the assessor identifies an unintended injury caused by medical management, rather than by the a 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: made no difference to the death report the impact of the CMI on the outcome using the following categories:

may have contributed to the death c aused the death of a patient who would otherwise have been expected to survive

definitely give their opinion of whether the CMI was preventable using the following categories:

probably probably not definitely not

indicate with whom the CMI was associated, using the following categories:

2.5

Obstetrician and gynaecologist assessors

2.6

Anaesthetist assessors

2.7

Providing feedback

audited surgical team another clinical team hospital

Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Fellows began participating in NTASM 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. These reviews are mostly of gynaecological cases.

Australian and New Zealand College of Anaesthetists (ANZCA) Fellows began participating in NTASM in August 2016. Anaesthetists voluntarily participate in the audit and self-assess the clinical management provided to a patient under review if the death was related to anaesthesia during surgery. NT anaesthetists also perform anaesthetic peer assessments (first- or second-line) for the Australian Capital Territory Audit of Surgical Mortality (ACTASM) and the Tasmanian Audit of Surgical Mortality (TASM). TASM and ACTASM anaesthetists correspondingly assess NTASM anaesthetic cases.

The core purpose of NTASM is to improve patient outcomes by providing detailed feedback to surgeons and hospitals to inform, educate, facilitate change and improve practice. Improvement at an individual, hospital or group level is achieved via feedback on individual cases; distribution of hospital reports, the National Case Note Review Booklet and the annual NTASM report; and provision of seminars.

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

2.8

Data analysis/reporting conventions

NTASM audits all surgery-related deaths occurring in NT hospitals. This 2023 report covers deaths reported to NTASM from 1 July 2018 to 30 June 2023 (census date 1 October 2023). The full audit process can take 3 months or longer from the initial notification of a death, so some 2023 cases were still under review as of the census date, with outcomes unavailable for this report. Case numbers in previous reports may differ from those in this report because some cases were completed after the relevant census dates. Patients admitted specifically for terminal care are excluded from the full audit process. Cases are included in the audit if the patient was admitted with the intention to treat but after assessment it was decided to manage the patient conservatively or to palliate. Data are entered and stored in the binational audit system database. Since data were incomplete for some cases (resulting from incomplete surgical case forms [SCFs] and assessment forms), the total number of cases for each analysis may vary.

2.9

Data management, storage and analysis

2.10

Statistical analysis

All data reported by NTASM are deidentified to preserve the confidentiality of the patient, the surgeon and the hospital. Data are encrypted and stored in a bespoke database. Transactions are time stamped and all changes to audit data are added to an archive table to provide a complete audit trail for each patient case. The database has an integrated workflow rules engine that enables NTASM staff to generate letters, reminders and management reports. NTASM staff routinely cross-check data for the online SCF, FLA and SLA forms. Data are cleaned using logic testing and manually reviewed before analysis.

Statistical analysis and graphs are performed using R (version 4.3.0) and RStudio (Version 2023.06.1 Build 524). Numbers in parentheses (n) in the text represent the number of cases analysed. The total number of patients used in each analysis varies because not all data points in the original SCF were completed. The total numbers of cases (n) included in individual analyses are provided in all tables and figures throughout the report. Continuous variables are summarised using medians and the interquartile range (IQR), where the IQR is the values of the 25th and 75th percentiles of the variable. Reporting IQRs overcomes the problem of reporting the range (minimum–maximum), as extreme values do not overly influence the interpretation of the data. Risk ratios (RRs) are calculated for variables that have a dichotomous outcome, to assess the risk of an event in one group (the comparator group) versus the risk of the event in another group (the reference group). All RRs are reported with a 95% confidence interval (CI). RRs are interpreted as follows: RR > 1: if patients in the comparator group are more likely to have the outcome of interest than patients in the reference group. RR ≈ 1: no difference or little difference in risk between patients in the comparator and reference groups (i.e. risk in each group is the same or similar). RR < 1: if patients in the comparator group are less likely to have the outcome of interest than patients in the reference group Statistical significance is set at p-value <0.05. A p-value is a statistical measurement used to validate a hypothesis against observed data. A p-value measures the probability of obtaining the observed results, assuming that the null hypothesis is true. The lower the p-value, the greater the statistical significance of the observed difference. (Statistical significance tells us that the sample effect is unlikely to be caused by sampling error. When we have statistically significant results, we conclude it is an actual effect existing in the population.) Qualitative responses are analysed by NTASM staff and classified into themes. Comorbidities and diagnoses for NT baseline data are provided by the NT Government with International Classification of Diseases (ICD) codes (10th revision, version 12). To enable comparison with NTASM data, NTASM recodes the ICD-10 categories to match the SCF categories.

NTASM REPORT (2023)

RESULTS

KEY POINTS 100% of NT surgeons participate in NTASM (n = 42). 100% of NT public and private hospitals participate in NTASM (n = 7). 0.9 days (IQR 21.2 – 132.3) is the average time taken by surgeons to complete and return 96.6% (396/410) of 6 SCFs. 54.3% (25/46) of feedback letters have been downloaded by surgeons since July 2022. 19.5% (64/328) of patients had a preoperative transfer. 87.1% (291/334) of patients had one or more comorbidities present. 81.3% (269/331) of patients received deep vein thrombosis (DVT) prophylaxis. 68.9% (230/334) of patients were treated in ICU. 81.1% (271/334) of patients had one or more operation. 465 operations were performed. 81.1% (377/465) of operations had a consultant surgeon present in theatre. 16.3% (54/332) of patients had a clinically significant infection. 22.2% (74/334) of patients were admitted to hospital due to trauma.

3.1

Audit participation

3.1.1

Deaths reported to NTASM

This report contains a comparative analysis of the 334 cases that completed the full peer-review process reported to NTASM from 1 July 2018 to 30 June 2023 (Table 2). A total of 410 deaths were reported to NTASM, of which 9 cases did not meet the inclusion criteria. Of the 401 cases that did meet NTASM criteria, 43 were excluded as terminal care, 14 cases are awaiting surgeon completion, and 10 cases are awaiting assessor completion. The full peer-review process was completed for 334 cases (93.3%, 334/358). NTASM feedback depends on timely completion of SCFs by surgeons. Throughout the reporting period, the median duration for surgeons to complete SCFs was 60.9 days (IQR 21.2 – 132.3). Table 2: NTASM cases at census date, 2018–2023 (n = 410) Notifications reported

2018–2019 n = 95

2019–2020 n = 76

2020–2021 n = 65

2021–2022 n = 91

2022–2023 n = 83

Total n = 410

Surgical case pending

0 (0.0%)

1 (1.1%)

13 (15.7%)

14 (3.4%)

95 (100.0%)

76 (100.0%)

65 (100.0%)

90 (98.9%)

70 (84.3%)

396 (96.6%)

Excluded case did not meet criteria

2 (2.1%)

0 (0.0%)

2 (3.1%)

2 (2.2%)

3 (4.3%)

9 (2.3%)

Excluded: terminal care

4 (4.2%)

10 (13.2%)

8 (12.3%)

10 (11.1%)

11 (15.7%)

43 (10.9%)

89 (93.7%)

66 (86.8%)

55 (84.6%)

78 (86.7%)

56 (80.0%)

344 (86.9%)

0 (0.0%)

10 (17.9%)

10 (2.9%)

89 (100.0%)

66 (100.0%)

55 (100.0%)

78 (100.0%)

46 (82.1%)

334 (97.1%)

Surgical case completed

Cases included Review process incomplete Review process complete

Reference: Appendix E, Data table 1 and Data table 2

The number of deaths notified to NTASM has decreased since 2018–2019. This could be in part due to COVID-19 impacting the number of surgical patients admitted to hospital in 2019–2020 and 2020–2021; reduced theatre access and staff availability.

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

3.1.2

Feedback downloaded by surgeons

Review of NTASM feedback can improve patient care. In June 2022, ANZASM implemented a new function of the audit system allowing surgeons to securely access, review and download their audit feedback online. Using this feature, NTASM can monitor the number of cases where surgeons have downloaded their feedback. NTASM began gathering this data in July 2022. From 1 July 2022 to 1 October 2023, NT surgeons had downloaded feedback for 54.3% (25/46) of cases.

3.1.3

Hospital participation

All public and private hospitals certified to provide surgical services in the NT participate in NTASM. These hospitals notified NTASM of 410 patient surgical deaths by the census date (1 October 2023). The NTASM review process was completed for 334 patients. Surgical deaths occurred predominantly in public hospitals (96.1%; 321/334), with a small percent in private hospitals (3.3%; 11/334) and co-located hospitals (0.6%; 2/334). According to the Australian Institute of Health and Welfare (AIHW), many interventions occur for acute overnight separations in the public sector in the NT, with no data provided for the private sector. A separation is a completed episode of care for an admitted patient. Some patients may have multiple separations during an admission (Section 8.4).1

3.1.4

Surgeon participation

Surgical specialty Surgeons participate in NTASM as treating surgeons (responsible for the case under review), peer-review surgeons providing FLAs or SLAs, locums or Specialist International Medical Graduates (SIMGs). As of 3 October 2023, 42 surgeons in the NT from 8 specialties were participating in the audit (Table 3). The NT relies extensively on locum surgeons and SIMGs, with 43 locums and 4 SIMGs currently participating in NTASM. The specialties with SIMGs are Vascular Surgery, Orthopaedic Surgery and General Surgery. Vascular Surgery, Urology and Neurosurgery currently have only one consultant surgeon each to serve public patients in the entire NT. Vascular and urology surgeons in Darwin also provide a locum service in Alice Springs. The Royal Darwin Hospital neurosurgery department reverted to depending on locum surgeons during 2021 and 2022 due to COVID-19. NTASM recommends a full-time-equivalent position for Neurosurgery and Vascular Surgery for both Alice Springs and Darwin. Table 3: Participating NT surgeons by surgical specialty, as of October 2023 Surgical specialty

Participating surgeons*

General

Orthopaedic

Otolaryngology Head and Neck

Oral and Maxillofacial

Plastic and Reconstructive

Neurosurgery

Urology

Vascular

*Excluded from this table are surgeons who are locums (n = 43), Specialist International Medical Graduates (n = 4) or ophthalmologists (n = 8) in the NT.

Surgeon views in retrospect Surgeons are asked in the SCF to consider whether—in retrospect—they would have done anything differently in terms of patient management. For 86.0% (283/329) of patients, the surgeon would not have changed the patient’s management. For 14.0% (46/329) of patients, the surgeon would have done something differently (no answer was provided for 1.5% (5/334) of patients). The areas of care identified by surgeons for improvement covered all aspects of patient management. Sample comments are provided in Section 8.3. This sample of comments highlight surgeons ability to self-reflect and learn from experience.

NTASM REPORT (2023)

Surgeon communication The SCF asks surgeons to indicate if the case involved a communication issue. Surgeons indicated communication was an issue in 6.6% (22/334) of cases; it was not an issue in 91.3% (305/334) of cases (unknown in the remaining cases). The SCF does not capture information about the source (e.g. patient, patient’s family or community, member of the clinical team) or nature (e.g. patient cognitive impairment, family unwilling to discuss palliative care) of the communication issue. Surgeon reports of communication issues have remained low over the 5-year reporting period of the audit (Table 4). Nevertheless, the NTASM Management Committee has identified communication as an area of focus for surgeons. During 2022, NTASM sponsored Safer Surgical Teamwork workshops at both Alice Springs and Darwin Hospital, which had a key focus on communication. It is hoped that this workshop has contributed to improved communication between treating teams. Table 4: Number of communication issues reported by treating surgeons (n = 334) 2018–2019

2019–2020

2020–2021

2021–2022

2022–2023

Total

Communication issues

No communication issues

305

Unknown

Total

334

Communication reported

Obstetrician and anaesthetist participation RANZCOG Fellows began participating in NTASM in 2012. Obstetricians and gynaecologists voluntarily participate in the audit if the patient’s death was gynaecology related. Seven obstetricians and gynaecologists participated, and 7 gynaecology cases were reported to NTASM. As this number is small, these cases are included in the total cases reported and not discussed separately as gynaecology cases. ANZCA Fellows began participating in NTASM in August 2016. Anaesthetists voluntarily participate in the audit if a patient’s death was possibly or definitely related to anaesthesia during surgery or it occurred within 48 hours of surgery. As of the census date, there were 34 participating anaesthetists, 7 of whom were general practitioner (GP) anaesthetists. Anaesthetist participation depends on the surgeon noting an anaesthetic-related death in the SCF or anaesthetists self-notifying NTASM of cases in which they are involved (Section 8.2). Some anaesthetists have selfreported cases to NTASM.

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

3.2

Demographic profile of audited cases

3.2.1

Sex and age of patients

Of the 334 NTASM patients, 196 were males and 138 were females. More males than females died during surgical admissions in NT hospitals in all years (2018–2023) (Appendix E, Data table 3). The median age of surgical patients who died was 67 years (IQR 54-77; n = 334). The most frequently occurring age (mode) across the 5-year NTASM reporting period was 78 years (Figure 1 and Appendix E, Data table 4 ). Figure 1: Age distribution of NTASM patients, 2018–2023 (n = 334) 45 40

Patients (n)

35 30 25 20 15 10 5

95 +

5– 9 10 –1 4 15 –1 9 20 –2 4 25 –2 9 30 –3 4 35 –3 9 40 –4 4 45 –4 9 50 –5 4 55 –5 9 60 –6 4 65 –6 9 70 –7 4 75 –7 9 80 –8 4 85 –8 9 90 –9 4

0– 4

Age groups in years Reference: Appendix E, Data table 5

NTASM REPORT (2023)

3.2.2

Comorbidities

Surgeons recorded all known comorbidities (coexisting medical conditions that threaten life). Most patients had at least 1 comorbidity (87.1%; 291/334); 43 patients had no comorbidities (12.9%; 43/334). Of those with comorbidities, 11.4% (33/289) had 1 comorbidity; 88.6% (256/289) had 2 or more comorbidities. The median number of comorbidities was 4 (IQR 2–5) and the maximum was 9. Cardiovascular disease (CVD) (67.1%) was the most frequently reported comorbidity (Figure 2 and Appendix E, Data table 6). The type of comorbidity was unreported for 2 patients. Figure 2: Types of comorbidities, 2018–2023 (n = 289*)

Patients (n)

150

100

Ob es ity

He pa tic

Ne ur ol og ica l

m al ig na nc y

Di ab et es

Ad an ce d

Ot he r

Re sp ira to ry

Re na l

Ag e

Ca rd io va sc ul ar

Comorbidity

*Data missing n = 2 Reference: Appendix E, Data table 6

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

3.3

Risk management strategies

3.3.1

Interhospital transfer

From 1 July 2018 to 30 June 2023, 19.5% (64/328) of audited deaths had interhospital transfers (data missing n = 6) and 16.7% (10/60) of those were reported to have had delays in the transfer (data missing n = 4). Table 5 shows the percentage of patients with interhospital transfers during the 5-year auditing period. The median transfer distance was 300 kilometres (IQR 100–575 kilometres). Surgeons reported that the transfer was appropriate for 98.4% (61/62) of transferred patients and there was sufficient clinical information provided together with the transfer in 96.8% (60/62) of audited deaths with transfer. Table 5: Audited deaths with transfer inter-hospitals and delay in transfer, 2018–2023 Year

Transfer*

Delay**

2018–2019

28.6% (24/84)

9.5% (2/21)

2019–2020

18.2% (12/66)

18.2% (2/11)

2020–2021

14.5% (8/55)

25.0% (2/8)

2021–2022

14.3% (11/77)

18.2% (2/11)

2022–2023

19.6% (9/46)

22.2% (2/9)

19.5% (64/328)

16.7% (10/60)

Total *Data missing n = 6 **Data missing n = 4

3.3.2

Prophylaxis for deep vein thrombosis

Deep vein thrombosis (DVT) prophylaxis is provided to most patients, regardless of whether they have an operation. Surgeons document any DVT prophylaxis used and comment on its appropriateness. Most patients were provided with DVT prophylaxis (81.3%; 269/331); 18.7% (62/331) did not receive DVT prophylaxis (data missing 0.9%; 3/334 cases). Surgeons stated they did not provide DVT prophylaxis to patients in the following situations: use not appropriate—71.0% (44/62) active decision to withhold—22.6% (14/62) use not considered—6.5% (4/62). Many surgeons gave additional reasons for not providing DVT prophylaxis to these patients (80.6%; 50/62) for the following reasons: active bleeding—42.0% (21/50) being coagulopathic—16.0% (8/50) already anticoagulated—10.0% (5/50) being palliated—14.0% (7/50). Some patients received more than one DVT prophylactic agent. Surgeons provided 438 different DVT prophylactic agents to 269 patients. The most frequently used DVT prophylaxis was heparin in any form (Table 6). Table 6: Types of DVT prophylaxis provided to NTASM patients, 2018–2023 Operative patients n = 365

Non-operative patients n = 73

Heparin (any form)

48.2% (176)

49.3% (36)

TED stockings

25.8% (94)

30.1% (22)

Sequential compression device

18.9% (69)

13.7% (10)

Aspirin

3.8% (14)

2.7% (2)

Other*

3.3% (12)

2.7% (2)

Warfarin

0.0% (0)

1.4% (1)

Type of DVT prophylaxis

DVT: Deep vein thrombosis; TED: Thromboembolic deterrent 438 uses of DVT prophylactic agent for 269 patients *Other includes apixaban, enoxaparin/Clexane and rivaroxaban/Xarelto, dual antiplatelet therapy, calf compressors, inferior vena cava filter already inserted.

NTASM REPORT (2023)

3.3.3

Provision of critical care support to patients

Planned or unplanned admission to ICU can occur at any time during a patient’s hospital stay, regardless of whether the patient has an operation or not. Surgeons record whether a patient was admitted to ICU. Nearly three-quarters of all NTASM patients were treated in ICU (68.9%; 230/334). Fewer patients who did not have an operation were treated in ICU (60.3%; 38/63) compared with those patients who had an operation (70.8%; 192/271), although this difference is not statistically significant (RR 0.85; 95% CI 0.69 to 1.05). Postoperative admission to ICU should be planned during preoperative assessments. Unplanned admission to ICU occurred in 21.5% (58/270) of the patients who had an operation. Unplanned admission to ICU is a reportable quality indicator used by the Australian Council of Healthcare Accreditation. It increases the risk of in-hospital mortality in geriatric trauma patients (those age 65 and older).2 The median age of patients treated in ICU was 64 years (IQR 48–74) and there were more male than female patients (132; 57.4% vs 98; 42.6%). Of the NTASM patients age 60 years or older, 16.8% (37/220) had an unplanned admission to ICU. Less than a quarter of NTASM patients were age 80 years or older (20.7%; 69/334); of these patients, 11.6% (8/69) had an unplanned admission to ICU. The median ASA class (American Society of Anesthesiologists physical status classification system) for patients treated in ICU was 4 (IQR 3–5), with 74.3% of patients (156/210; data missing n = 20) at class 4 or higher. Some NT patients require interhospital transfer to receive ICU treatment. Of the 53 patients transferred and treated in ICU, 20.8% (11/53) did not have an operation.

3.4

Profile of operative intervention

3.4.1

Operation Frequency

In this report, the term operation encompasses both operations and procedures (i.e. a relevant radiological or endoscopic procedure).3 Most NTASM patients admitted under the care of a surgeon had an operation (81.1%; 271/334). Two-thirds of patients (69.7%; 189/271) had one operation; 18.9% (63/334) of patients did not have an operation. Surgeons performed 465 operations, with consultant surgeons performing 59.1% (275/465) of these operations. Table 7 shows the most frequently performed operations across 2018–2023, representing 54.2% (252/465) of all operations. Table 7: Most frequently performed operations, 2018–2023 (n = 252) Operation

Frequency (n)

Percentage (%)

Debridement of skin NEC

8.2

Diagnostic gastroscopy NEC

7.7

Reopening of laparotomy site

7.5

Exploratory laparotomy

6.9

Burr hole(s) for ventricular external drainage

5.4

Debridement of muscle NEC

5.2

Irrigation of peritoneal cavity

3.4

Change of dressing

3.0

Dressing of wound

2.6

Delayed closure of abdomen

2.2

Diagnostic endoscopic retrograde examination of bile and pancreatic ducts

2.2

NEC = not elsewhere classified

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

3.4.2

Preoperative diagnostic delays

Delays in surgical diagnosis are associated with higher mortality rates in surgical patients.4 During 2018–2023, 8.1% (22/271) of patients had a delay in surgical diagnosis. Delays in surgical diagnosis were highest in 2018–2019 and lowest in 2022–2023 (Figure 3 and Appendix E, Data table 7). Causes of delays can be associated with more than one department or area. Most delays were associated with surgical departments (40.9%; 9/22), medical departments (18.2%; 4/22), GPs (13.6%; 3/22) or other (40.9%; 9/22). Nearly half of the delays in surgical diagnosis were due to unavoidable factors (45.5%; 10/22). Twelve patients experienced delays associated with the wrong test being done, results not seen, misinterpretation of results or inexperienced staff (these are too few to report individually). Figure 3: Delays in surgical diagnoses for NTASM patients who had an operation, 2018–2023 (n = 271)

Cases with delays in surgical diagnosis (%)

14 12 10 8 6 4 2 0

2018–2019

2019–2020

2020–2021

2021–2022

2022–2023

Year

Cases with delays in surgical diagnosis (%)

Reference: Appendix E, Data table 7

14 12 10 8 6 4 2 0 2018-2019 2019-2020 2020-2021

2021-2022 2022-2023

Year Specialty Vascular Surgery NTASM REPORT (2023)

Urology

Paediatric Surgery

3.4.3

ASA class

Anaesthetists use the ASA physical status classification system to assess preoperative risk based on a patient’s comorbidities and other factors. Classification levels range from class 1 (normal healthy patient) to class 6 (declared brain-dead).5 NTASM surgeons record the ASA class for all patients, regardless of whether they receive an operation. The median ASA class for patients who had an operation was 4 (IQR 3–4), with 72.1% of patients (186/258) classified 4 or higher. This implies severe systemic disease that is a constant threat to life (Figure 4). Surgeons did not report the ASA class for 4.8% (13/271) of patients who had an operation. Figure 4: ASA class for NTASM patients who had an operation, 2018–2023 (n = 258*) 50

Patients recorded ASA Class (%)

45 40 35 30 25 20 15 10 5 0

ASA Class *Data missing n = 13 ASA: American Society of Anesthesiologists; ASA class 1 = a normal healthy patient; ASA class 2 = a patient with mild systemic disease; ASA class 3 = a patient with severe systemic disease; ASA class 4 = a patient with severe systemic disease that is a constant threat to life; ASA class 5 = a moribund patient 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. Reference: Appendix E, Data table 8

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

3.4.4

Surgeon perception of preoperative risk of death

Surgeons assess each patient’s risk of death. Risk of death, while subjective, reflects the complexity of the procedure in the context of the patient’s presentation, estimated physiological reserve and ASA class. Surgeons assessed 70.6% (190/269) of patients as having a moderate or considerable risk of death before an operation (data missing n = 2). Death was expected for 17.1% (46/269) of patients who underwent at least one operation (Figure 5). Figure 5: Surgeon-assessed risk of death for operative patients, 2018–2023 (n = 269*)

45 40

Patients (%)

35 30 25 20 15 10 5 0

Minimal

Small

Moderate

Considerable

Expected

Risk of Death Data missing n = 2 Reference: Appendix E, Data table 9

NTASM REPORT (2023)

3.4.5

Consultant surgeon in theatre: operating, assisting or supervising

Consultant surgeons may be in theatre to perform, assist with or supervise an operation. ‘Consultant present in theatre’ answers on the SCF depend on the treating surgeon comprehensively completing the questions relating to the operation. When patients have multiple operations performed by surgeons from different specialties, the treating surgeon (completing the SCF) is required to complete all the operation questions. A total of 465 operations were performed. The presence of consultant surgeons in any capacity (i.e. performing, assisting with, or supervising the operation) was 81.1% (377/465). Consultants performed 59.1% (275/465) of operations, assisted in 9.9% (46/465) of operations or were in theatre in an unspecified capacity for 12.0% (56/465) of operations (Figure 6). The frequency of consultants operating has remained above 50.0% across all years.

Consultant surgeon presence in theatre (%)

Figure 6: Operations conducted with a consultant surgeon present in theatre, 2018–2023 (n = 465) 70 60 50 40 30 20 10 0

2018–2019

2019–2020

2020–2021

2021–2022

2022–2023

Year Consultant: Assist

Consultant: In Theatre

Consultant: Operate

Consultant in theatre = consultant surgeon may have performed, assisted with, or supervised the operation (not specified) Reference: Appendix E, Data table 10

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

3.4.6

Postoperative complications

Postoperative complications occurred in 21.9% (59/269) of patients in 2018–2023. The frequency of postoperative complications has steadily decreased from 24.7% of all operations in 2018–2019 to 17.1% in 2022–2023 (Figure 7 and Appendix E, Data table 11). A delay in recognising postoperative complications occurred in 10.2% (6/59) of patients who had a complication (data not shown).

Patients with postoperative complications (%)

Figure 7: NTASM patients with postoperative complications, 2018–2023 (n = 269*)

2018–2019

2019–2020

2020–2021

2021–2022

2022–2023

Year Some patients had several complications *Data missing n = 2 Reference: Appendix E, Data table 11

Postoperative complications are listed by frequency in Appendix E, Data table 12. Surgeons did not report the type of complication for every patient. Some patients had several complications. The most frequently recorded complications were: procedure-related sepsis—17.9% (10/56) significant postoperative bleeding—17.9% (10/56) tissue ischaemia—8.9% (5/56) anastomotic leak—8.9% (5/56) endoscopic perforation—3.6% (2/56).

NTASM REPORT (2023)

3.4.7

Unplanned return to theatre

Unplanned returns to theatre are strong predictors of death. On average, 19.9% (54/271) of patients who died postoperatively had an unplanned return to theatre (Table 8). Compared to previous years, the percentage of patients who had an unplanned return to theatre decreased in 2022-2023. Table 8: Unplanned return to theatre, 2018–2023 (n = 271) Operated patients (n)

Unplanned return to theatre (n)

Percentage (%)

2018–2019

16.4

2019–2020

28.3

2020–2021

23.4

2021–2022

21.0

2022–2023

8.3

Total

271

19.9

Year

3.5

Infections

Surgeons document whether patients died with a clinically significant infection present at the time of death, and whether any infections were present at the time of admission or developed during the hospital admission. More than a third of NTASM patients (38.0%; 126/332; data missing n = 2) had a clinically significant infection present at the time of death. More patients acquired the infection before admission to hospital (56.8%; 71/125) than during admission (43.2%; 54/125) (data missing n = 1; data not shown). When the infection was acquired during admission, 7.4% (4/54) of patients acquired it preoperatively and 59.2% (32/54) acquired it postoperatively; 20.4% (11/54) had a surgical site infection and 13.0% (7/54) had other invasive site infections (data not shown). Pneumonia was the most frequent type of infection acquired during admission (55.6%; 30/54) (Table 9). Table 9: Infection type in NTASM patients who acquired a clinically significant infection during admission, 2018– 2023 (n = 54) Type of infection

n (%)

Pneumonia

30 (55.6)

Intra-abdominal sepsis

14 (25.9)

Septicaemia

5 (9.3)

Other source

5 (9.3)

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

The infective organism was identified in 55.6% of patients (69/124; data missing n = 2). Patients may be infected with multiple organisms. Infective organisms included bacteria, viruses, and yeasts. More infections were due to bacterial infections than either yeasts or viruses. Group A Streptococcus was the cause of most bacterial infections (Table 10). Table 10: Most frequently identified infective bacteria, viruses and yeasts in NTASM patients, 2018–2023 (n = 69) Bacteria

Viruses

Yeasts

Group A Streptococcus

Coronavirus

Candida albicans/Candida species

Staphylococcus aureus

Influenza A

Cryptococcus species

Pseudomonas species

Escherichia coli

Enterobacter

Streptococcus

Klebsiella species

Vancomycin-resistant enterococci

Burkholderia

3.6

Trauma

Surgeons are asked to document whether patients were admitted to hospital due to trauma and, if so, the cause of the trauma. More than one-fifth of patients (22.2%; 74/334) were admitted due to trauma. The most frequent causes of trauma were falls (56.8%; 42/74), traffic incidents (21.6%; 16/74) or violence (16.2%; 12/74). The most frequent locations of falls were in private homes (71.4%; 30/42), hospitals (11.9%; 5/42) and care facilities 9.5%; 4/42) or at other locations. Other fall locations were places of sport, recreation, farming or work (Table 11). Table 11: Patient location at time of trauma-causing fall, 2018–2023 (n = 42) Location

n (%)

Home

30 (71.4)

Hospital

5 (11.9)

Care facility

4 (9.5)

Other*

3 (7.1)

*Other includes sport, recreation, farming or work locations.

Of all traffic incidents, 93.8% involved either a motor vehicle (13/16) or a motorcycle (2/16). Pedestrians were involved in traffic incidents but were too few to report (Appendix E, Data table 13). Public violence 58.3% (7/12) and self-inflicted violence 33.3% (4/12) were the main causes of trauma related to violence.

NTASM REPORT (2023)

PEER-REVIEW OUTCOMES

KEY POINTS 100% of audited cases had a first-line assessment and 10.2% (34/334) had a second-line assessment. 58.8% (20/34) of second-line assessments were due to insufficient information. 86.2% (288/344) of patients had no clinical management issues. 70 clinical management issues were identified in 46 patients. 29 serious clinical management issues were preventable.

4.1

Second-line assessments

The peer-review process comprises a retrospective examination of the clinical management of patients who died while under the care of a surgeon. All assessors (first- and second-line) must decide whether the death was a direct result of the disease process alone or if aspects of patient management may have contributed to the outcome. All cases undergo an FLA, where the first-line assessor decides whether the treating surgeon has provided enough information to allow an informed decision to be reached on the appropriateness of the case management. If inadequate information was provided or if further clarification was needed, the first-line assessor requests an SLA. During the auditing period, an SLA was requested for 10.2% (34/334) of audited cases, of which 58.8% (20/34) was due to insufficient information. This could be avoided by more comprehensive completion of SCFs by surgeons.

4.2

Deep vein thrombosis prophylaxis

Assessors report on whether surgeon use or non-use of DVT prophylaxis was appropriate. Figure 8 shows assessors’ opinions on the appropriateness of DVT prophylaxis by year. Figure 8: Assessor-perceived appropriateness of DVT prophylaxis by year, 2018–2023 (n = 329*)

Appropriate use or non−use of DVT (%)

90 80 70 60 50 40 30 20 10 0

2018–2019

2019–2020

2020–2021

2021–2022

2022–2023

Year appropriateness

inappropriateness

unknown

*Data missing for n = 5 Reference: Appendix E, Data table 14

Between 2018 and 2023, assessors indicated that the decision to use or withhold DVT prophylaxis was appropriate in 78.1% (257/329) of cases. In 1.8% (6/329) of cases, assessors reported that there had been an inappropriate decision regarding the use or non-use of DVT prophylaxis. Assessors could not comment on the appropriateness of the DVT prophylaxis decision in 20.1% (66/329) of cases.

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

The percentage of assessors who agree with the decision to use or withhold DVT prophylaxis has declined over the reporting period (2018–2023). Conversely, the percentage of assessors unable to comment on the appropriateness of DVT prophylaxis has increased over the same period. This may be due to insufficient information being provided by the treating surgeon or in the medical notes.

4.3

Use of ICU/critical care units

Assessors report on whether the decision not to treat a patient in ICU or a critical care unit (CCU) was appropriate and/ or if the patient would have benefited from treatment in ICU/CCU. The proportion of patients not treated in a CCU and assessors’ opinions of ICU/CCU use over time are shown in Table 12. The percentage of patients not treated in ICU/CCU during 2022–2023 was higher (43.5%; 20/46) than previous years, although assessors reported that none of these patients would have benefited from care in ICU or CCU. Assessors reported that overall 4.8% (5/104) of patients who were not treated in ICU, would have benefited from ICU admission. This was highest during 2020–2021, when assessors reported that 3 patients would have benefited from care in ICU or CCU. Table 12: Audited deaths without use of ICU/CCU, 2018–2023 Year

Without use of care units

Would have benefited

2018–2019

29.2% (26/89)

3.8% (1/26)

2019–2020

30.3% (20/66)

0.0% (0/20)

2020–2021

30.9% (17/55)

17.6% (3/17)

2021–2022

26.9% (21/78)

4.8% (1/21)

2022–2023

43.5% (20/46)

0.0% (0/20)

31.1% (104/334)

4.8% (5/104)

Total

4.4

Clinical management issues

A primary objective of the peer-review process is to determine whether a patient’s death was a direct result of the disease process alone, or if aspects of patient management might have contributed to the outcome. First- and secondline assessors consider areas of the care pathway that could have been improved. These CMIs are classified as: an area of consideration (the lowest level of concern) an area of concern an adverse event (the most serious level of concern). CMIs reported are those from the highest level of assessment (i.e. from the SLA, if performed). Most audited cases (86.2%; 288/334) had no reported CMIs. A total of 70 CMIs were recorded in 13.8% of patients (46/334), indicating that a patient can have more than 1 CMI (data not shown). For these patients, the most serious CMI was included in the analysis for this report (Section 2.4). CMIs were classified as an area of consideration for 7.5% of patients (25/334), an area of concern for 3.9% of patients (13/334) and an adverse event for 2.4% (8/334) of patients (data not shown).

4.4.1

Perceived impact of clinical management issues

Using a 3- or 4-point scale, first-line and second-line assessors were asked to indicate: 1. What impact did any perceived issues of patient management have on the clinical outcome? 2. Were these issues preventable? 3. Which clinical team was responsible for the issue? Table 13 shows the frequency of assessor-identified CMIs grouped by the level of seriousness (consideration, concern, adverse event). Of the 46 most serious CMIs, assessors considered that 50.0% (23/46) of these CMIs may have contributed to the death of the patient, 37.0% (17/46) made no difference, and 13.0% (6/46) caused the death of a patient otherwise expected to survive. Of the most serious CMIs, more than half (65.9%; 29/44) were considered preventable, with 15.9% (7/44) considered definitely preventable (data missing n = 2). CMIs can be associated with more than one clinical team. Assessors reported that more than half of the CMIs were associated with the surgical team (58.7%; 27/46).

NTASM REPORT (2023)

Table 13: Impact of CMI according to assessor and most frequent issue, 2018–2023 (n = 46) Consideration n = 25

Concern n = 13

Adverse n=8

Total n = 46

Made no difference

64.0% (16/25)

7.7% (1/13)

0.0% (0/8)

37.0% (17/46)

May have contributed to death

32.0% (8/25)

84.6% (11/13)

50.0% (4/8)

50.0% (23/46)

Caused the death of a patient otherwise expected to survive

4.0% (1/25)

7.7% (1/13)

50.0% (4/8)

13.0% (6/46)

Definitely preventable

8.0% (2/25)

25.0% (3/12)

28.6% (2/7)

15.9% (7/44)

Probably preventable

44.0% (11/25)

58.3% (7/12)

57.1% (4/7)

50.0% (22/44)

Probably not preventable

40.0% (10/25)

16.7% (2/12)

14.3% (1/7)

29.5% (13/44)

Definitely not preventable

8.0% (2/25)

0.0% (0/12)

0.0% (0/7)

4.5% (2/44)

Issues Impact of CMI on clinical outcome

Preventability of CMI (data missing n = 2)

Associated clinical team (some CMIs may be associated with more than one clinical team) Surgical team

56.0% (14/25)

53.8% (7/13)

75.0% (6/8)

58.7% (27/46)

Another clinical team

24.0% (6/25)

30.8% (4/13)

25.0% (2/8)

26.1% (12/46)

Hospital issue

8.0% (2/25)

7.7% (1/13)

12.5% (1/8)

8.7% (4/46)

Other*

12.0% (3/25)

7.7% (1/13)

12.5% (1/8)

10.9% (5/46)

CMI: clinical management issue *Other associations include nursing home, anaesthetics team and emergency department Note: not all assessors reported on the preventability of CMIs

4.4.2

Areas of consideration

Assessors classified 54.3% (25/46) of CMIs as areas of consideration and considered that 32.0% (8/25) of these may have contributed to the death of the patient and 4.0% (1/25) caused the death of a patient otherwise expected to survive. These events were considered preventable in 52.0% (13/25) of these audited deaths. These preventable events were mostly associated with the surgical team (69.2%; 9/13). The most frequent preventable events were delay to surgery, delay in receiving blood transfusion and delay in transfer to the surgeon by physicians 30.8% (4/13).

4.4.3

Areas of concern and adverse events

Assessors classified 45.7% (21/46) of CMIs as areas of concern or adverse events. Assessors considered that 71.4% (15/21) of these CMIs may have contributed to the death of the patient and 23.8% (5/21) caused the death of a patient who was otherwise expected to survive. These CMIs were preventable in 76.2% (16/21) of these audited deaths with CMIs. These preventable events were mostly associated with the surgical team (62.5%; 10/16). The most frequent preventable events were: better to have performed a different operation, a more extensive operation or a more limited operation (31.3%; 5/16) delay to surgery, delay in diagnosis or delay in recognising complications (18.8%; 3/16).

4.4.4

Preventable clinical management issues

Assessors classified 65.9% (29/44) of all CMIs as definitely or probably preventable. Among these CMIs, assessors considered that 48.3% (14/29) may have contributed to the death of a patient and 13.8% (4/29) caused the death of a patient otherwise expected to survive. These preventable CMIs were mostly associated with the surgical team (65.5%; 19/29). The most frequent preventable events were: better to have performed a different operation, a more extensive operation or a more limited operation, or an operation should have been performed (24.1%; 7/29) delay to surgery, delay in diagnosis, delay in transfer to the surgeon by the physician, delay in blood transfusion or delay in recognising complications (24.1%; 7/29).

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

ABORIGINAL AND TORRES STRAIT ISLANDER PATIENTS

5.1

Overview

KEY POINTS Aboriginal and Torres Strait Islander patients compared to non-Indigenous patients were: more likely to be younger than age 50 and were on average 18 years younger more likely to be female and to be transferred and admitted to a public hospital similar regarding the presence of comorbidities more likely to have an operation if admitted under a general surgeon more likely to present to hospital with an infection CMIs did not occur in 86.0% (104/121) of Aboriginal and Torres Strait Islander patients. The RACS 2020 Indigenous health position paper reaffirms the College’s commitment to improving health outcomes for Aboriginal and Torres Strait Islander people.6 Aboriginal and Torres Strait Islander people in Australia experience poorer health outcomes compared with non-Indigenous people. Disease burden is 2 times higher in Aboriginal and Torres Strait Islander people than in non-Indigenous people. Contributing to this increased disease burden are CVD, cancer, musculoskeletal conditions, diabetes and chronic respiratory disease. These rates increase at a younger age in Aboriginal and Torres Strait Islander patients than in nonIndigenous patients.7,8 Adult Aboriginal and Torres Strait Islander people are more likely to have 3 or more comorbidities (38%) compared with adult non-Indigenous people (26%).8 Differences in patient characteristics between NTASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients are shown in Table 14. NTASM Aboriginal and Torres Strait Islander patients are, on average, 18 years younger than non-Indigenous patients and 3 times more likely to be younger than 50 years of age. There was no statistical difference in the presence of 3 or more comorbidities between Aboriginal and Torres Strait Islander patients and non-Indigenous patients with comorbidities (Table 14). Aboriginal and Torres Strait Islander patients were 3 times more likely to be transferred than were non-Indigenous patients. Aboriginal and Torres Strait Islander patients were more likely to present to hospital with an infection compared with non-Indigenous patients (Table 14).

NTASM REPORT (2023)

Table 14: Characteristics and clinical outcomes of NTASM Aboriginal and Torres Strait Islander patients and nonIndigenous patients, 2018–2023 (n = 334) Aboriginal and Torres Strait Islander patients n = 121 (36.2%)

Non-Indigenous patients n = 213 (63.8%)

Mean (±SD)

53 (17)

70 (16)

Median (IQR)

56 (46–66)

74 (62–81)

0–86

18–99

45/121 (37.2)

23/213 (10.8)

3.44 (2.20 to 5.40)*

Female

68/121 (56.2)

70/213 (32.9)

1.71 (1.33 to 2.19)*

Male

53/121 (43.8)

143/213 (67.1)

0.65 (0.52 to 0.82)*

Transferred

43/120 (35.8)

21/208 (10.1)

3.55 (2.22 to 5.68)*

Public hospital admission

120/121 (99.2)

201/213 (94.4)

1.05 (1.01 to 1.09)*

Emergency admission

114/121 (94.2)

191/213 (89.7)

1.05 (0.99 to 1.12)

Comorbidities present

105/121 (86.8)

183/213 (85.9)

1.01 (0.92 to 1.10)

≥3 Comorbidities present

78/105 (74.3)

135/183 (73.8)

1.01 (0.87 to 1.16)

Operation performed

107/121 (88.4)

164/213 (77.0)

1.15 (1.04 to 1.27)*

Delay in diagnosis

13/121 (10.7)

12/213 (5.6)

1.91 (0.90 to 4.05)

Postoperative complication

18/107 (16.8)

41/162 (25.3)

0.66 (0.40 to 1.09)

Fluid balance issue

16/119 (13.4)

18/213 (8.5)

1.59 (0.84 to 3.00)

Clinically significant infection

51/121 (42.1)

75/211 (35.5)

1.19 (0.90 to 1.56)

Community acquired infection

35/121 (28.9)

36/211 (17.1)

1.69 (1.13 to 2.55)*

Hospital acquired infection

16/121 (13.2)

38/211 (18.0)

0.73 (0.43 to 1.26)

Demographics

Age at death (years)

Range Age 0–49 years Sex

Risk ratio (95% CI)

Denominator variation occurs because not all questions were answered. *Statistically significant at p<0.05 but may not be clinically significant. The lower the p-value, the greater the statistical significance of the observed difference (Section 2.10). Note: The risk ratio reference group is non-Indigenous patients. Risk ratio (RR) and 95% confidence interval (CI) are presented. RR is the risk of having the characteristic of interest in one group divided by the risk of having the characteristic of interest in the reference group. RR is alternately called relative risk (Section 2.10).

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

5.2

Age

The age-adjusted life expectancy gap (at birth) between Aboriginal and Torres Strait Islander people and nonIndigenous people is 8 years for males and 7 years for females. Life expectancy for Aboriginal and Torres Strait Islander people decreases by 6–7 years for those living in remote and very remote areas.7 For NTASM patients, the average age gap between Aboriginal and Torres Strait Islander patients and non-Indigenous patients is 18 years. Male Aboriginal and Torres Strait Islander patients were 21 years younger and female patients were 16 years younger than male and female non-Indigenous patients (Figure 9). More NTASM Aboriginal and Torres Strait Islander patients were transferred from remote and very remote regions, which could account for the persistently large age gap between Aboriginal and Torres Strait Islander patients and non-Indigenous patients. Figure 9: Median age of NTASM Aboriginal and Torres Strait Islander and non-Indigenous patients by year and gender, 2018–2023 (n = 334)

Age in years (median)

2018–2019

2019–2020

2020–2021

2021–2022

2022–2023

Years Aboriginal and Torres Strait Islander – Female

Non−Indigenous – Female

Aboriginal and Torres Strait Islander – Male

Non−Indigenous – Male

Reference: Appendix E, Data table 15

NTASM REPORT (2023)

5.3

Comorbidities

Comorbidities remain higher in Aboriginal and Torres Strait Islander people than non-Indigenous people. The AIHW July 2023 report on changes in health status and outcomes for Aboriginal and Torres Strait Islander people reported that death rates due to CVD and kidney disease had decreased, death rates due to cancer had increased and death rates due to diabetes were unchanged.7 Comparisons of comorbidities in NTASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients are seen in Table 15. Aboriginal and Torres Strait Islander patients were 2 times more likely to have renal disease and diabetes. There was no significant difference in the presence of CVD between Aboriginal and Torres Strait Islander patients and non-Indigenous patients. NTASM Aboriginal and Torres Strait Islander patients were less likely to have advanced malignancy than were nonIndigenous patients. Nevertheless, the AIHW reported in 2023 that cancer is currently the leading cause of death among Aboriginal and Torres Strait Islander patients (increasing from 10% to 12% between 2010 and 2019).7 Table 15: Most frequent comorbidities in NTASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients, 2018–2023 (n = 334) Comorbidities

Aboriginal and Torres Strait Islander patients (n = 121) (%)

Non-Indigenous patients (n = 213) (%)

Risk ratio (95% CI)

Cardiovascular

76 (62.8)

117 (54.9)

1.14 (0.95 to 1.37)

Renal

68 (56.2)

52 (24.4)

2.30 (1.73 to 3.06)*

Diabetes

60 (49.6)

42 (19.7)

2.51 (1.82 to 3.48)*

Other**

45 (37.2)

60 (28.2)

1.32 (0.96 to 1.81)

Respiratory

35 (28.9)

78 (36.6)

0.79 (0.57 to 1.10)

Hepatic

26 (21.5)

38 (17.8)

1.20 (0.77 to 1.88)

Advanced malignancy

22 (18.2)

60 (28.2)

0.65 (0.42 to 1.00)*

Neurological

19 (15.7)

49 (23.0)

0.68 (0.42 to 1.10)

Obesity

11 (9.1)

21 (9.9)

0.92 (0.46 to 1.85)

Patients often have more than one comorbidity; 1,022 comorbidities were reported for 289 patients. *Statistically significant at p<0.05 but may not be clinically significant. The lower the p-value, the greater the statistical significance of the observed difference (Section 2.10). **Other includes alcohol abuse, anticoagulation, dementia/Alzheimer’s disease, depression, frailty, immunosuppression, leukaemia, malnutrition, paraplegia, peripheral vascular disease, rheumatoid arthritis, smoking. Note: The risk ratio reference group is non-Indigenous patients. Risk ratio (RR) and 95% confidence interval (CI) are presented. RR is the risk of having the characteristic of interest in one group divided by the risk of having the characteristic of interest in the reference group. RR is alternately called relative risk (Section 2.10).

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

5.4

Operations

Overall, Aboriginal and Torres Strait Islander patients were more likely to have an operation than were non-Indigenous patients. Aboriginal and Torres Strait Islander patients admitted under a general surgeon were more likely to have an operation than were non-Indigenous patients admitted under general surgeons (Table 16). Table 16: Distribution of NTASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients admitted by surgical specialty and percentage who had an operation, 2018–2023 (n = 334) Aboriginal and Torres Strait Islander patients who had an operation (n = 121) (%)

Non-Indigenous patients who had an operation (n = 213) (%)

Risk ratios (95% CI)

General Surgery

64/70 (91.4)

108/147 (73.5)

1.24 (1.1 to 1.4)*

Neurosurgery

17/24 (70.8)

13/16 (81.3)

0.87 (0.62 to 1.24)

Orthopaedic Surgery

11/12 (91.7)

25/26 (96.2)

0.95 (0.79 to 1.15)

Other**

15/15 (100.0)

18/24 (75.0)

1.33 (1.06 to 1.68)*

Specialty

Specialities are not reported where patient numbers are fewer than 5. *Statistically significant at p<0.05 but may not be clinically significant. The lower the p-value, the greater the statistical significance of the observed difference (Section 2.10). **Other includes vascular, urology, plastic and reconstructive, otolaryngology head and neck, ophthalmology, obstetrics and gynaecology, oral/maxillofacial surgery. Note: The risk ratio reference group is non-Indigenous patients. Risk ratio (RR) and 95% confidence interval (CI) are presented. RR is the risk of having the characteristic of interest in one group divided by the risk of having the characteristic of interest in the reference group. RR is alternately called relative risk (Section 2.10).

5.5

Peer-review outcomes

Assessors found no significant difference in the operative care provided to Aboriginal and Torres Strait Islander patients and that provided to non-Indigenous patients (Table 17). First-line assessors were significantly more likely to request an SLA for Aboriginal and Torres Strait Islander patients than for non-Indigenous patients. SLAs were completed for 16.5% (20/121) of Aboriginal and Torres Strait Islander patients, and for 6.6% (14/213) of non-Indigenous patients. (RR 2.51; 95% CI 1.32 to 4.79) (data not shown). Table 17: Assessor-perceived difference in care provided to NTASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients who had an operation, 2018–2023 (n = 271) Aboriginal and Torres Strait Islander patients (n = 107) (%)

Non-Indigenous patients (n = 164) (%)

Risk ratio (95% CI)

Preoperative care

6/107 (5.6)

11/161 (6.8)

0.82 (0.31 to 2.15)

Decision to operate

6/107 (5.6)

9/163 (5.5)

1.02 (0.37 to 2.77)

Timing of operation

6/107 (5.6)

8/162 (4.9)

1.14 (0.41 to 3.18)

Postoperative care

7/107 (6.5)

6/163 (3.7)

1.78 (0.61 to 5.14)

Assessor-perceived difference in care

Results to be treated with caution as numbers are low. Note: The risk ratio reference group is non-Indigenous patients. Risk ratio (RR) and 95% confidence interval (CI) are presented. RR is the risk of having the characteristic of interest in one group divided by the risk of having the characteristic of interest in the reference group. RR is alternately called relative risk (Section 2.10).

5.5.1

Clinical management issues

No CMIs were reported for most Aboriginal and Torres Strait Islander patients (86.0%; 104/121) and is similar to nonIndigenous patients (86.4%; 184/213). A total of 28 CMIs were reported for 17 Aboriginal and Torres Strait Islander patients (14%; 17/121), indicating that a patient can have more than one CMI. Only the most serious CMI per patient is included in the following analysis. Among the 17 patients with CMIs, assessors considered that the most serious CMIs were areas of consideration (5.8%; 7/121), areas of concern (4.1%; 5/121) and adverse events (4.1%; 5/121). Of these CMIs, 71.4% (5/7) of the perceived areas of consideration made no difference to the death; all (100.0%; 5/5) of the areas of concern may have contributed to the death and 40.0% (2/5) of the adverse events caused the death of the patient. In those who had an operation, 16 patients (15%; 16/107) had CMIs compared with 1 patient (7.1%; 1/14) among those who did not have an operation. For patients who had an operation, 37.5% (6/16) of CMIs were areas of consideration, 31.3% (5/16) were areas of concern and 31.3% (5/16) were adverse events. Of the 10 patients with assessor-identified CMIs considered areas of concern and/or adverse events, assessors noted that 8 CMIs were preventable and 2 CMIs caused the death of the patient.

NTASM REPORT (2023)

NT BASELINE PATIENTS 2022

The NT Department of Health provides NTASM with baseline data from patients who had a surgical procedure in an NT public hospital and were discharged from hospital. These NT baseline data include patients admitted to any NT public hospital between January and December 2022 who had a surgical procedure or operation that was performed by a surgeon and required a general anaesthetic. The patient may have been admitted by a physician or a surgeon. The data reflect the last admission for each patient and exclude patients reported to NTASM. A total of 17,310 baseline patients were admitted between January and December 2022. Non-surgical obstetrics patients and those having non-surgical dental or allied health procedures (n = 4,501) were excluded from the comparison. The remaining 12,809 patients had a total of 15,480 admissions, with 2,671 patients having readmissions (ranging from 1 to 12 readmissions). Comparisons are based on the last admission for each patient.

6.1

Characteristics of NT baseline and NTASM patients

The characteristics of NT baseline patients and NTASM patients admitted during the same period are in Table 18. The proportion of Aboriginal and Torres Strait Islander patients was higher among NT baseline patients compared with NTASM patients. More NTASM patients had emergency admissions than did baseline patients, and the proportion of NTASM patients with comorbidities was nearly double that of baseline patients. The greatest differences were seen in the proportions of patients with diabetes, respiratory disease, renal disease, CVD, and hepatic disease. The proportion of NTASM patients with ASA classifications 1–3 was lower than for baseline patients. Overall, infections occurred in fewer NT baseline patients (18.1%; 2,303/12,809) than in NTASM patients (42.7%; 32/75). Table 18 shows the occurrence of hospital acquired infections was the same in both groups (14.9%—baseline patients and 14.7%—NTASM patients). In NT baseline patients, the most frequently identified organisms were Staphylococcus and Streptococcus. NTASM patients had a similar proportion of Streptococcus infections but much fewer Staphylococcus infections. Postoperative complications occurred in 5.0% (642/12,809) of NT baseline patients compared with 17.3% (13/75) of NTASM patients. The most frequent complications in baseline patients were wound sepsis (1.9%), other complication (0.9%), haemorrhage (0.7%) and orthopaedic internal device (0.5%) Trauma due to falls occurred in 6.5% (833/12,809) of NT baseline patients compared with 13.3% (10/75) of NTASM patients.

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

Table 18: Characteristics of NT baseline and NTASM patients, January to December 2022 NT baseline patients (n = 12,809)

NTASM patients (n = 75)

Female

6,894 (53.8%)

46 (61.3%)

Male

5,910 (46.1%)

29 (38.7%)

5 (0.0%)

0 (0.0%)

Emergency

5,359 (50.8%)

68 (90.7%)

Elective

6,501 (41.8%)

7 (9.3%)

949 (7.4%)

0 (0.0%)

Aboriginal and/or Torres Strait Islander

4,977 (38.9%)

24 (32.0%)

Non-Indigenous

7,827 (61.1%)

51 (68.0%)

5 (0.0%)

0 (0.0%)

Comorbidities present*

7,284 (56.9%)

66 (88.0%)

Diabetes

2, 357 (18.4%)

23 (30.7%)

Respiratory

1,413 (11.0%)

30 (40.0%)

Cardiovascular

1,326 (10.4%)

44 (58.7%)

Renal

1,052 (8.2%)

30 (40.0%)

Obesity

580 (4.5%)

11 (14.7%)

Hepatic

313 (2.4%)

21 (28.0%)

Dementia**

53 (0.4%)

17 (22.7%)

3,578 (27.9%)

Coronavirus present

522 (4.1)

Alcoholic hepatic disease

59 (0.5%)

Rheumatic heart disease

17 (0.1%)

History of alcohol use

464 (3.6%)

1 (1–3)

14 (6–30)

Class 1

2,566 (20.0%)

0 (0.0%)

Class 2

5,733 (44.8%)

1 (1.3%)

Class 3

2,736 (21.4%)

17 (22.7%)

Class 4

357 (2.8%)

40 (53.3%)

Class 5

5 (0.0%)

13 (17.3%)

Class 6

0 (0.0%)

3 (4.0%)

Unknown/not stated/missing

1,412 (11.0%)

1 (1.3%)

Infection present

2,303 (18.1%)

32 (42.7%)

Hospital acquired infection

1,903 (14.9%)

11 (14.7%)

181 (1.4%)

3 (4.0%)

Characteristics Sex

Unknown/inadequately described Admission status

Not assigned Indigenous status

Unknown

Smoking

Length of hospital stay, median days (IQR) ASA classification

Sepsis

NTASM REPORT (2023)

Table 18: Characteristics of NT baseline and NTASM patients, January to December 2022 NT baseline patients (n = 12,809)

NTASM patients (n = 75)

Staphylococcus

1,284 (10.0%)

1 (1.3%)

Streptococcus

558 (4.4%)

3 (4.0%)

Other bacteria

151 (1.2%)

6 (8.0%)

Pseudomonas

116 (0.9%)

6 (8.0%)

E. coli

115 (0.9%)

2 (2.7%)

Klebsiella

50 (0.4%)

3 (4.0%)

Candida

87 (0.7%)

5 (6.7%)

Complication present

642 (5.0%)

13 (17.3%)

Wound sepsis

243 (1.9%)

2 (2.7%)

Other complication

112 (0.9%)

8 (10.7%)

Haemorrhage

96 (0.7%)

2 (2.7%)

Internal device – orthopaedic

68 (0.5%)

Cardiovascular device/vascular graft

50 (0.4%)

0 (0.0%)

Accidental perforation

24 (0.2%)

0 (0.0%)

Anastomotic leak with haemorrhage

17 (0.1%)

1 (1.3%)

Anaesthetic complication

17 (0.1%)

1 (1.3%)

Trauma due to fall

833 (6.5%)

10 (13.3%)

Characteristics Infective organism identified

IQR: interquartile range ASA = American Society of Anesthesiologists; ASA class 1 = a normal healthy patient; ASA class 2 = a patient with mild systemic disease; ASA class 3 = a patient with severe systemic disease; ASA class 4 = a patient with severe systemic disease that is a constant threat to life; ASA class 5 = a moribund patient 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. Note: All NT baseline patients were discharged from hospital and all NTASM patients died in hospital. Note: Comorbidities and diagnoses for NT baseline data are provided by the NT Government with International Classification of Diseases codes (ICD-10). To enable comparison with NTASM data, NTASM recodes the ICD-10 categories to match categories in the SCF. *The number of variables supplied with the baseline data was similar to that provided with the 2020 data. **Dementia in NTASM patients is recorded as neurological.

6.2

Comorbidities

A higher percentage of NT baseline patients (43.1%) had no comorbidities compared with NTASM patients (12.2%) (Table 19). Only 1.1% of NT baseline patients had 5 or more comorbidities compared with 28.0% (21/75) of NTASM patients. Table 19: Comorbidity frequency in NT baseline and NTASM patients, January to December 2022 NT baseline patients (n = 12,809)

NTASM patients (n = 75)

5,525 (43.1%)

9 (12.0%)

3,870 (30.2%)

7 (9.3%)

2,072 (16.2%)

8 (10.7%)

873 (6.8%)

14 (18.7%)

324 (2.5%)

16 (21.3%)

106 (0.8%)

16 (21.3%)

39 (0.3%)

5 (6.7%)

Comorbidities

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

6.3

Age

The age of NT baseline patients forms a normal distribution compared to a bimodal distribution for NTASM patients. In general, NT baseline patients were younger than NTASM patients (Figure 10).

16 14 12 10 8 6 4 2

40 –4 4 45 –4 9 50 –5 4 55 –5 9 60 –6 4 65 –6 9 70 –7 4 75 –7 9 80 –8 4 85 –8 9 90 –9 4

10 –1 4 15 –1 9 20 –2 4 25 –2 9 30 –3 4 35 –3 9

5– 9

0– 4

Percentage of patients within age group (%)

Figure 10: NT baseline and NTASM patients by age group, January to December 2022

Age Group NT baseline patients

NTASM patients

Patients >95 years excluded (2 NT baseline patients; 1 NTASM patient) Reference: Appendix E, Data table 16

NTASM REPORT (2023)

REFERENCES

1. Queensland Health, Statistical Services Branch. Queensland Hospital Admitted Patient Data Collection (QHAPDC): Admission and separation date/time. State of Queensland (Queensland Health). 2017 [accessed 01 December 2023]. Available from: https://www.health.qld.gov.au/__data/assets/pdf_file/0026/656423/info-sheet-adm-sepv1.0.pdf 2. Mulvey HE, Haslam RD, Laytin AD, Diamond CA, Sims CA. Unplanned ICU admission is associated with worse clinical outcomes in geriatric trauma patients. J Surg Res. 2020 Jan;245:13-21. doi: 10.1016/j.jss.2019.06.059. Epub 2019 Aug 5. PMID: 31394403. Available from: https://www.journalofsurgicalresearch.com/article/S00224804(19)30455-X/fulltext 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, 2019–20. [accessed 01 December 2023]. Available from: https://www.aihw.gov.au/about-our-data/our-data-collections/national-hospitals 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?login=false 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. Royal Australasian College of Surgeons. Indigenous Health Position Paper June 2020. Available from: https://www. surgeons.org/-/media/Project/RACS/surgeons-org/files/interest-groups-sections/indigenous-health/RACSIndigenous-Health-Position-Statment-FINAL-July2020.pdf?rev=f3f6592c396240ff95d1e2181a3f9276&hash=7A6 AA309F899C8171491E99489F228AB 7. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework: summary report July 2023. Canberra: AIHW. 2023 [accessed 01 December 2023]. Available from: https://www. indigenoushpf.gov.au/report-overview/overview/summary-report?ext=. 8. Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples: 2015, Cat. no. IHW 147.AIHW, Australian Government, accessed 01 December 2023. doi:10.25816/5ebcbd26fa7e4 [accessed 01 December 2023]. Available from: https://www.aihw.gov.au/reports/ indigenous-australians/indigenous-health-welfare-2015/contents/table-of-contents

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

APPENDICES

8.1

Appendix A: NTASM governance structure

Data figure 1: NTASM governance structure

Ministers of health

RACS Council

RACS Professional Standards and Fellowship Services Committee Government departments of health RACS Surgical Audit Committee

Participating hospitals ANZASM Steering Committee

Consultant surgeons

RACS Audit of Surgical Mortality Management Committee

Project staff

NTASM REPORT (2023)

8.2

Appendix B: NTASM audit process

Data figure 2: NTASM audit process NTASM receives notification of death

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

SCF completed online and returned to the NTASM and deidentified

Surgeon documents anaesthetic component to the death

Anaesthetic case form is sent to anaesthetist in hard copy for completion

Completed anaesthetic case form is returned to the NTASM and deidentified

SCF is sent for FLA* Anaesthetic case form (if relevant) is also sent for FLA**

Yes Clinical Director selects second assessor

SLA*

Is an SLA required?

Case closed including FLA

Feedback to surgeon

Has an appeal been lodged against the SLA?

Case closed

Yes Clinical Director selects additional second-line assessor

Additional SLA*

Feedback to surgeon

Case closed

*First- and second-line assessors for NTASM are peer surgeons from a different state **Anaesthetists from Tasmania and Australian Capital Territory perform assessments on NT Anaesthetic cases. NTASM: Northern Territory Audit of Surgical Mortality; SCF: surgical case form: FLA: first-line assessment; SLA: second-line assessment

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

8.3

Appendix C: Surgeons report what they would have done differently

This sample of comments highlight surgeons’ ability to self-reflect and learn from experience. Aspect of patient management

Comments Patient has a poor prognosis with large amount of bleed, it was after discussion with another neurosurgeon, related to the patient, that a trial of life procedure was performed. The decision was made with the understanding that alleviating the hydrocephalus was the main aim, not reversing the damage from the bleed. It was an informed decision to go ahead with the procedure. Alternatively, if the family had agreed for palliation, the surgery would not have been performed.

Decision to operate

The patient probably shouldn`t have had surgery as the mortality rate in a patient over 80 with an acute subdural haemorrhage is over 80%. In hindsight, I would have preferred not to have taken this patient to theatre. The patient was a high-risk candidate for bowel resection and had previously refused elective surgery. Given the patient’s co-morbidities, a stoma would have been a safer option, but the patient was adamant that he did not want a stoma and knew the risks of possible leak prior to the operation. In hindsight, given the patient’s poor Eastern Cooperative Oncology Group (ECOG) Performance Status score, co-morbidities and almost certain diagnosis of a high-grade brain tumour, this patient should have been palliated from the onset. Would have asked radiology to consider embolising the left gastric artery in view of warning haemorrhage. They may not have agreed because there was no blush on computed tomography (CT) angiogram immediate post bleed. Would have anchored the drain with multiple dressings: probably in the situation at night in theatre I did not pay adequate attention. Drain was anchored with a silk suture and single dressing around it. Adequately dealing with the sub-hepatic collection may have altered the patient’s clinical course if the surgical interventions below were considered:

Different procedure

an endoscopic retrograde cholangio-pancreatography (ERCP) and stent insertion to decompress biliary system and control the bile leak. an open cholecystectomy to control the source of the leak with washout of the perihepatic collection I would have done the Hartmann`s procedure without the flexible sigmoidoscopy. At initial operation, I would have defunctioned the bowel after resection rather than performed an anastomosis and should have had a closer look at the liver. Different surgical approach to epiploic vein. Obtain earlier access to the operating theatre. Single surgical consultant involved in overseeing patient`s management from admission to discharge and follow-up

Earlier operation

In response to the question from the in-charge anaesthetist re: whether this was immediately life-threatening (with the examples given: airway obstruction and active bleeding). I would have said yes, rather than replying that I wanted the patient in theatre within 1 hour. This prompted the anaesthetist to change the booking request from an A to a B+. I would also have refused the anaesthetist`s request for a COVID-19 swab before proceeding and performed the case in COVID-19 precautions. I believe that agreeing to the swab gave theatre/the anaesthetist the impression that the case could wait for the result. Earlier return to theatre. Looked closer at small bowel after adhesiolysis at original op. More thorough exploration of the stomach posteriorly.

NTASM REPORT (2023)

Aspect of patient management

Comments Expect an exit wound, more thorough inspection posteriorly. Managed more intensively to prevent lower lobe collapse and pneumonia. My initial contact with the patient was in the Surgical Acute Care Unit and exploration was performed on the same day. The left leg infection and spreading extensive cellulitis was evident on clinical examination and ongoing need of vasopressors due to septic shock. To my understanding, attributing the septic shock to left leg cellulitis when there was radiological evidence of pan colitis must have been challenging to the admitting team. Application of necrotising fasciitis score (laboratory risk indicator for necrotizing fasciitis - LRINEC) and a cutdown to fascia on the day of admission might have enabled an earlier diagnosis. Whether this would have contributed to a better outcome is debatable. Reviewed need for external ventricular drain (EVD) directly with neurosurgeon. Involving the family in the decision-making process for a below knee amputation on the very first day could have avoided a trans metatarsal amputation and the need for a second operation. Taking biopsy under local anaesthesia from the skin lesions early The team who performed the patient’s mastectomy should have followed her throughout. The acute team should have made sure the patient’s haematoma resolved and that the patient was getting nutrition. More aggressive investigations and management implementations. Should have spoken to patient and family in more detail about the specific medical complications that could arise from the intervention ... paying particular attention to both the patient’s and family’s expectations on resuscitation and level of intervention. Clinical assessment and blood tests may have detected the sepsis early.

Other

Better social support is beyond the capability of surgical team and the patient shouldn`t have spent a lengthy time in the hospital.

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

8.4

Appendix D: Data definitions

1. Surgical case form (SCF): A structured questionnaire completed by the treating surgeon associated with the case. Treating surgeons enter SCF responses into a bespoke online database—the RACS Audit of Surgical Mortality Fellows Interface. 2. Anaesthetic case form: A structured questionnaire optionally completed by the anaesthetist associated with the case (anaesthetist participation is voluntary). This form is available only in hard copy. 3. First-line assessment (FLA): Case assessment conducted by a surgeon from the same speciality as the treating surgeon. The first-line assessor reviews the SCF (not patient files) and enters responses into the RACS Fellows Interface. The first-line assessor will either close the case or recommend further assessment by a second-line assessor. 4. Second-line assessment (SLA): Case assessment conducted by a surgeon from the same speciality as the treating surgeon. Second-line assessors are generally specialists in the area under review. First- and second-line assessors respond to the same set of questions; however, SLAs are more in-depth and forensic because these assessors can access all medical records. NTASM provides second-line assessors with a letter summarising issues to be addressed in their report. 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 this warrants further investigation the patient’s death was unexpected (i.e. a healthy patient not expected to die) information provided by the treating 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 by publication as a case note review. Surgeons can appeal the findings of an SLA, in which case the Clinical Director selects an additional independent second-line assessor. This has not occurred in NTASM to date. 5. Separation: 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 the patient is transferred to another hospital/care facility or leaves the hospital against medical advice.1 6. Operation: refers to operations and procedures. In this report, an operation may refer to a relevant radiological or endoscopic procedure as well as a surgical procedure.3

NTASM REPORT (2023)

8.5

Appendix E: Performance review data

Data table 1: Status of all NTASM cases at time of census, 2018–2023 (n = 410) n (%)

Status SCF pending

14 (3.4)

FLA pending

2 (0.5)

SLA pending

5 (1.2)

Reviewed

334 (81.5)

Excluded: terminal care

43 (10.5)

Excluded: error*

9 (2.2)

Medical records pending

1 (0.2)

Total

410 (100.0)

*Excluded error: death notified to NTASM, but the reported death is excluded by NTASM, as it does not meet the criteria. SCF: surgical case form; FLA: first-line assessment; SLA: second-line assessment

Data table 2: Notifications of surgical deaths reviewed by NTASM by year, 2018–2023 (n = 334) Year

2018–2019

2019–2020

2020–2021

2021–2022

2022–2023

Data table 3: Sex ratio of NTASM patients by year, 2018–2023 (n = 334) Male

Female

Year

Total (%)

2018–2019

53 (59.6)

36 (40.4)

2019–2020

35 (53.0)

31 (47.0)

2020–2021

34 (61.8)

21 (38.2)

2021–2022

49 (62.8)

29 (37.2)

2022–2023

25 (54.3)

21 (45.7)

Total

196 (58.7)

138 (41.3)

Data table 4: Age distribution of NTASM patients, 2018–2023 (n = 334) Age statistics Mean (SD) Median (IQR)

Age of NTASM patients (years) 64 (18) 67 (54–78)

Mode

Minimum

Maximum

SD: standard deviation; IQR: interquartile range

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

Data table 5: Age of NTASM patients in 5-year age groups, 2018–2023 (n = 334) Age group (years)

n (%)

0–4

3 (0.9)

5–9

0 (0.0)

10–14

0 (0.0)

15–19

6 (1.8)

20–24

6 (1.8)

25–29

5 (1.5)

30–34

3 (0.9)

35–39

10 (3.0)

40–44

10 (3.0)

45–49

25 (7.5)

50–54

17 (5.1)

55–59

29 (8.7)

60–64

30 (9.0)

65–69

39 (11.7)

70–74

36 (10.8)

75–79

46 (13.8)

80–84

40 (12.0)

85–89

17 (5.1)

90–94

10 (3.0)

95+

2 (0.6)

Total

334 (100.0)

Data table 6: Most frequent comorbidities in NTASM patients, 2018–2023 (n = 289*) Comorbidities

n (%)

Cardiovascular

194 (67.1)

Age

142 (49.1)

Renal

120 (41.5)

Respiratory

113 (39.1)

Other**

105 (36.3)

Diabetes

102 (35.3)

Advanced malignancy

82 (28.4)

Neurological

68 (23.5)

Hepatic

64 (22.1)

Obesity

32 (11.1)

Patients often have more than one comorbidity. A total of 1,022 comorbidities were reported for 289 patients. *Data missing n = 2 **Other includes alcohol abuse, anticoagulation therapy, arthritis/osteoporosis, dementia/Alzheimer’s disease, cerebral palsy, hyperthyroidism, malignancy, malnutrition/cachexia, peripheral vascular disease, smoking, ischaemic heart disease.

NTASM REPORT (2023)

Data table 7: Delays in surgical diagnoses for NTASM patients who had an operation, 2018–2023 (n = 271) Year

n (%)

2018–2019

11 (15.1)

2019–2020

3 (5.7)

2020–2021

3 (6.4)

2021–2022

4 (6.5)

2022–2023

1 (2.8)

Total

22 (8.1)

Data table 8: ASA class for NTASM patients who had an operation, 2018–2023 (n = 258*) ASA class

n (%)

1 (0.4)

7 (2.7)

64 (24.8)

129 (50.0)

53 (20.5)

4 (1.6)

Total

258 (100.0)

*Data missing n = 13 ASA: American Society of Anesthesiologists; ASA class 1 = a normal healthy patient; ASA class 2 = a patient with mild systemic disease; ASA class 3 = a patient with severe systemic disease; ASA class 4 = a patient with severe systemic disease that is a constant threat to life; ASA class 5 = a moribund patient, 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.

Data table 9: Surgeon-assessed risk of death for operative patients, 2018–2023 (n = 269*) Surgeon's preoperative view of overall risk of death

n (%)

Minimal

14 (5.2)

Small

19 (7.1)

Moderate

60 (22.3)

Considerable

130 (48.3)

Expected

46 (17.1)

*Data missing n = 2

Data table 10: Consultant surgeon presence in theatre, 2018–2023 (n = 465) Consultant presence in theatre

2018–2019 n = 121 (%)

2019–2020 n = 96 (%)

2020–2021 n = 78 (%)

2021–2022 n = 104 (%)

2022–2023 n = 66 (%)

Total n = 465 (%)

Consultant: Operate

70 (57.9)

48 (50)

52 (66.7)

63 (60.6)

42 (63.6)

275 (59.1)

Consultant: Assist

21 (17.4)

8 (8.3)

4 (5.1)

9 (8.7)

4 (6.1)

46 (9.9)

19 (15.7)

13 (13.5)

11 (14.1)

11 (10.6)

2 (3)

56 (12)

110 (90.9)

69 (71.9)

67 (85.9)

83 (79.8)

48 (72.7)

377 (81.1)

Consultant: In theatre Total

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

Data table 11: NTASM postoperative complications by year, 2018–2023 (n = 269*) Year

n (%)

2018–2019

18 (24.7)

2019–2020

12 (23.1)

2020–2021

11 (23.4)

2021–2022

12 (19.4)

2022–2023

6 (17.1)

Total

59 (21.9)

*Data missing n = 2

Data table 12: Postoperative complications in NTASM patients, 2018–2023 (n = 56*) Postoperative complication

Patients (n)

Patients with complication (%)

Procedure-related sepsis

17.9

Significant postoperative bleeding

17.9

Tissue ischaemia

8.9

Anastomotic leaks

8.9

Endoscopic perforation

3.6

Other

58.9

*Data missing n = 3

Data table 13: Type of road traffic incidents that caused trauma, 2018–2023 (n = 16) Road traffic incident

n (%)

Motor vehicle accident

13 (81.3)

Motorbike accident

2 (12.5)

Bicycle accident

0 (0.0)

Pedestrian accident

0 (0.0)

Unknown

0 (0.0)

Other

1 (6.3)

Data table 14: Assessor-perceived appropriateness of DVT prophylaxis per year, 2018–2023 (n = 329*) Year

Inappropriate % (n/d)

Appropriate % (n/d)

No comment % (n/d)

2018–2019

0.0% (0/85)

90.6% (77/85)

9.4% (8/85)

2019–2020

3.1% (2/65)

78.5% (51/65)

18.5% (12/65)

2020–2021

0.0% (0/55)

74.5% (41/55)

25.5% (14/55)

2021–2022

2.6% (2/78)

74.4% (58/78)

23.1% (18/78)

2022–2023

4.3% (2/46)

65.2% (30/46)

30.4% (14/46)

Total

1.8% (6/329)

78.1% (257/329)

20.1% (66/329)

*Data missing n = 5

NTASM REPORT (2023)

Data table 15: Median age of NTASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients by year and sex, 2018–2023 (n = 334) Aboriginal and Torres Strait Islander patients n = 121

Non-Indigenous patients n = 213

Year

Female n = 68

Male n = 53

Female n = 70

Male n = 143

2018–2019

60 (50–64)

48 (30–64)

74 (58–82)

75 (67–81)

2019–2020

55 (49–68)

53 (19–62)

62 (57–73)

71 (61–80)

2020–2021

52 (48–63)

54 (43–61)

67 (59–79)

76 (69–79)

2021–2022

48 (44–50)

59 (43–67)

78 (57–80)

74 (64–82)

2022–2023

65 (57–69)

57 (47–66)

72 (68–76)

82 (59–88)

Age as median and interquartile range

Data table 16: Age of baseline and NTASM patients in 5-year age groups, January to December 2022 NT baseline patients n = 12,809

NTASM patients n = 75

0–4

478 (3.7%)

0 (0%)

5–9

536 (4.2%)

0 (0%)

10–14

466 (3.6%)

0 (0%)

15–19

511 (4%)

0 (0%)

20–24

631 (4.9%)

0 (0%)

25–29

884 (6.9%)

1 (1.3%)

30–34

938 (7.3%)

1 (1.3%)

35–39

983 (7.7%)

4 (5.3%)

40–44

892 (7%)

1 (1.3%)

45–49

946 (7.4%)

10 (13.3%)

50–54

1,073 (8.4%)

4 (5.3%)

55–59

1,046 (8.2%)

1 (1.3%)

60–64

982 (7.7%)

6 (8%)

65–69

876 (6.8%)

12 (16%)

70–74

753 (5.9%)

6 (8%)

75–79

456 (3.6%)

8 (10.7%)

80–84

242 (1.9%)

12 (16%)

85–89

92 (0.7%)

5 (6.7%)

90–94

22 (0.2%)

3 (4%)

95+

2 (0%)

1 (1.3%)

Total

12,809 (100.0%)

75 (100.0%)

Age group (years)

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS

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NTASM REPORT (2023)