Trends in utilisation of ultrasound by older Australians (2010-2019).

BACKGROUND: Older people have increasingly complex healthcare needs, often requiring appropriate access to diagnostic imaging, an essential component of their health and disease management planning. Ultrasound is a safe imaging tool used to diagnose several conditions commonly experienced by older people such as deep vein thrombosis. PURPOSE: To evaluate the utilisation of major ultrasound services by Australians ≥ 65 years old between 2009- and 2019. METHODS: This population-based and yearly cross-sectional study of ultrasound utilisation per 1,000 Australians ≥ 65 years old was conducted using publicly available data sources. Overall, examination site and age- and sex-specific incidence rate (IR) of ultrasound per 1,000 people, adjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated using negative binomial regression models. RESULTS: Over the study period, the crude utilisation of ultrasound increased by 83% in older Australians. Most ultrasound examinations were conducted on extremities (39%) and the chest (21%), with 25% of all ultrasounds investigating the vascular system. More men than women use ultrasounds of the chest (184/1,000 vs 268/1,000 people), particularly echocardiograms (177/1,000 vs 261/1,000 people), and abdomen (88/1,000 vs 92/1,000 people), especially in those ≥ 85 years old. Hip and pelvic ultrasound were used more by women than men (212/1,000 vs 182/1,000 people). There were increases in vascular abdominal (IRR:1.07, 95%CI:1.06-1.08) and extremeties (IRR:1.06, 95%CI:1.05-1.07) ultrasounds over the study period, particularly in ≥ 75 years old men. CONCLUSIONS: Ultrasound is a common and increasingly used diagnostic tool for conditions commonly experienced by older Australians.

Peer review of mortality after hepatectomy in Australia.

BACKGROUND: The data within the Australian and New Zealand Audit of Surgical Mortality (ANZASM) provides a unique opportunity to consider the contributing factors to perioperative deaths as determined by peer review. Consideration of the factors contributing to mortality after hepatectomy can provide greater insight into how deaths can be prevented. The objective of this study was to determine the reasons for patient deaths post-hepatectomy in Australia. METHODS: ANZASM data from 1 January 2010 to 30 Jun 2017 was reviewed and all deaths following hepatectomy were selected for analysis. Assessors determinations of whether management could have been improved were reviewed, and then classified into groups of significant clinical events using thematic analysis with a data driven approach. RESULTS: The study included 88 deaths reported to ANZASM after hepatectomy. The assessors questioned the decision to operate in 23/88 (25%) patients with a further nine (10%) patients insufficiently investigated prior to resection. ANZASM assessors determined that there was a delay in recognising a significant complication in 16/88 (18%) patients. CONCLUSION: Multi-disciplinary decision making is strongly recommended when deciding which patients to treat with hepatic resection. Optimal care post-hepatectomy includes early recognition of complications and enactment of an adequate rescue plan.

Peer review of mortality after pancreaticoduodenectomy in Australia.

BACKGROUND: The data within the Australian and New Zealand Audit of Surgical Mortality (ANZASM) provides a unique opportunity to consider the contributing factors to perioperative deaths as determined by peer review. Consideration of the factors contributing to mortality after pancreaticoduodenectomy (PD) can provide greater insight into how deaths can be prevented. METHODS: ANZASM data from 1 January 2010 to 30 Jun 2017 was reviewed and all deaths following PD were selected for analysis. Assessor's determination of whether management could have been improved were reviewed and classified into groups of significant clinical events using thematic analysis with a data driven approach. RESULTS: The study included 87 deaths reported to ANZASM after PD. Forty-two major complications were considered significant clinical events in 29/84 (35%) of patients. The assessor determined that there was a delay in recognising a significant complication in 18/84 (21%) of patients. In 14/84 (17%) of patients, ANZASM assessment questioned the decision to operate. CONCLUSION: Multi-disciplinary decision making is strongly recommended when deciding which patients to treat with PD. Late recognition, and therefore delayed action to treat complications, in almost a quarter of deaths is a significant finding that warrants consideration for clinicians involved in the postoperative care of PD patients.

Perioperative Mortality Following Oesophagectomy and Pancreaticoduodenectomy in Australia.

INTRODUCTION: Oesophagectomy (OG) and pancreaticoduodenectomy (PD) remain associated with significant perioperative mortality rates (POMR). Improved outcomes in high-volume centres have led to these procedures being centralised in some countries. This retrospective, population-based cohort study was conducted to determine the Australian national, and state and territory based POMR associated with OG and PD, and assess trends over time. METHODS: Logistic regression analysis was performed using de-identified procedural data between 1 July 2005 and 30 June 2013 from the Australian Institute of Health and Welfare. Codes relating to OG and PD contained in the Australian Classification of Health Interventions were used to extract patient data. Mortality rates were risk adjusted for age, gender and urgency of admission. Temporal trends and differences between states/territories were investigated. RESULTS: The average Australian POMR throughout the study period was 3.5 and 3.0% for OG and PD, respectively. OG POMR showed no significant change over time (P = 0.30) or variation between states (P = 0.079). The annual POMR associated with PD, however, showed a significant decrease during the study period (P = 0.01) with variation in PD POMR outcomes evident amongst different regions (P = 0.0004). CONCLUSION: This study demonstrates a comparable Australian PD and OG POMR when correlated with international studies. National PD POMR improved throughout the study with consistent improvement across the states and territories. This study does, however, show variation in PD POMR between states and territories. Potential intra-state variation merits further investigation.

Perioperative Mortality Rates in Australian Public Hospitals: The Influence of Age, Gender and Urgency.

INTRODUCTION: A decline in surgical deaths has been observed in Australia since the introduction of the Australian and New Zealand Audit of Surgical Mortality (ANZASM). The current study was conducted to determine whether the perioperative mortality rate (POMR) has also declined. METHODS: This study is a retrospective review of the POMR for surgical procedures in Australian public hospitals between July 2009 and June 2013, using data obtained from the Australian Institute of Health and Welfare. Operative procedures contained in the Australian Refined Diagnosis Related Groups were selected and the POMR was modelled using urgency of admission, age and gender as explanatory covariates. RESULTS: The POMR in Australian public hospitals reduced by 15.4 % over the 4-year period. The emergency admissions POMR dropped from 1.40 to 1.12 %, and the elective admissions POMR from 0.09 to 0.08 %. The binary logistic regression model used to predict patient mortality showed emergency admissions to have a higher POMR than elective, being more evident at older ages. For emergency admissions, the difference in POMR between females and males increased with age, from about 55 years onwards, with females being lower. For elective surgeries, the difference between males and females was of little practical importance across ages. CONCLUSIONS: The reduction in the POMR in Australia confirms the reduction in surgical deaths reported to ANZASM. Continuing to monitor POMR will be important to ensure the safest surgery in Australia. Further investigations into case-mix will allow better risk adjustment and comparison between regions and time-periods, to facilitate continuous quality improvement.

Potentially avoidable mortality after endoscopic retrograde cholangiopancreatography in Australia: an 8-year qualitative analysis.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure worldwide. The aim of this study was to examine cases of mortality after ERCP to identify clinical incidents that are potentially preventable, to improve patient safety. METHODS: The Australian and New Zealand Audit of Surgical Mortality provides an independent and externally peer-reviewed audit of surgical mortality pertaining to potentially avoidable issues. A retrospective review of prospectively collected data within this database was performed for the 8-year audit period from 1 January 2009 to 31 December 2016. Clinical incidents were identified by assessors through first- or second-line review, and thematically coded into periprocedural stages. These themes were then qualitatively analysed. RESULTS: There were 58 potentially avoidable deaths following ERCP, with 85 clinical incidents. Preprocedural incidents were most common (n = 37), followed by postprocedural (n = 32) and then intraprocedural (n = 8). Communication issues occurred across the periprocedural period (n = 8). Preprocedural incidents included delay to procedure, inadequate resuscitative management, decision to perform procedure and inadequate assessment. Intraprocedural incidents comprised technical factors and inadequate support. Postprocedural incidents involved inappropriate treatment, delay in definitive surgical treatment or in recognizing complications, inappropriate second-line intervention and inadequate assessment. Communication incidents comprised inadequate documentation, failure to escalate care and poor inter-clinician communication. CONCLUSION: Causes of mortality following ERCP are wide-ranging, and reviewing clinical incidents associated with potentially avoidable mortality can serve to inform and educate practitioners. In collating a subset of cases in which procedure-related mortality was deemed avoidable, a series of cautionary tales about ERCP is presented that may provide cues to practitioners on improving patient safety and inform future surgical practice.

In-hospital survival after pancreatoduodenectomy is greater in high-volume hospitals versus lower-volume hospitals: a meta-analysis.

BACKGROUND: Variation in cut-off values for what is considered a high volume (HV) hospital has made assessments of volume-outcome relationships for pancreaticoduodenectomy (PD) challenging. Accordingly, we performed a systematic review and meta-analysis comparing in-hospital mortality after PD in hospitals above and below HV thresholds of various cut-off values. METHOD: PubMed/MEDLINE, Embase and Cochrane Library were searched to 4 January 2021 for studies comparing in-hospital mortality after PD in hospitals above and below defined HV thresholds. After data extraction, risk of bias was assessed using the Downs and Black checklist. A random-effects model was used for meta-analysis, including meta-regressions. Registration: PROSPERO, CRD42021224432. RESULTS: From 1855 records, 17 observational studies of moderate quality were included. Median HV cut-off was 25 PDs/year (IQR: 20-32). Overall relative risk of in-hospital mortality was 0.37 (95% CI: 0.30, 0.45), that is, 63% less in HV hospitals. All subgroup analyses found an in-hospital survival benefit in performing PDs at HV hospitals. Meta-regressions from included studies found no statistically significant associations between relative risk of in-hospital mortality and region (USA vs. non-USA; p = 0.396); or 25th percentile (p = 0.231), median (p = 0.822) or 75th percentile (p = 0.469) HV cut-off values. Significant inverse relationships were found between PD hospital volume and other outcomes. CONCLUSION: In-hospital survival was significantly greater for patients undergoing PDs at HV hospitals, regardless of HV cut-off value or region. Future research is required to investigate regions where low-volume centres have specialized PD infrastructure and the potential impact on mortality.

Mesh versus non-mesh repair of groin hernias: a rapid review.

BACKGROUND: Mesh is frequently utilized intraoperatively for the repair of groin hernias. However, patients may request non-mesh hernia repairs owing to adverse events reported in other mesh procedures. To inform surgical safety, this study aimed to compare postoperative complications between mesh and non-mesh groin hernia repairs and identify other operative and patient-related risk factors associated with poor postoperative outcomes. METHODS: Ovid MEDLINE and grey literature were searched to 9 June 2021 for studies comparing mesh to non-mesh techniques for primary groin hernia repair. Outcomes of interest were postoperative complications, recurrence of hernia, pain and risk factors associated with poorer surgical outcomes. Methodological quality was appraised using the AMSTAR 2 tool. RESULTS: The systematic search returned 4268 results, which included seven systematic reviews and five registry analyses. Mesh repair techniques resulted in lower hernia recurrence rates, with no difference in chronic pain, seroma, haematoma or wound infection, compared to non-mesh techniques. Risk factors associated with increased risk of hernia recurrence were increased body mass index (BMI), positive smoking status and direct hernia. These were independent of surgical technique. Patients under 40 years of age were at increased risk of postoperative pain. CONCLUSIONS: Surgical repair of primary groin hernias using mesh achieves lower recurrence rates, with no difference in safety outcomes, compared with non-mesh repairs. Additional risk factors associated with increased recurrence include increased BMI, history of smoking and hernia subtype.

Impact of COVID-19, gender, race, specialty and seniority on mental health during surgical training: an international study.

BACKGROUND: Superior patient outcomes rely on surgical training being optimized. Accordingly, we conducted an international, prospective, cross-sectional study determining relative impacts of COVID-19, gender, race, specialty and seniority on mental health of surgical trainees. METHOD: Trainees across Australia, New Zealand and UK enrolled in surgical training accredited by the Royal Australasian College of Surgeons or Royal College of Surgeons were included. Outcomes included the short version of the Perceived Stress Scale, Oxford Happiness Questionnaire short scale, Patient Health Questionnaire-2 and the effect on individual stress levels of training experiences affected by COVID-19. Predictors included trainee characteristics and local COVID-19 prevalence. Multivariable linear regression analyses were conducted to assess association between outcomes and predictors. RESULTS: Two hundred and five surgical trainees were included. Increased stress was associated with number of COVID-19 patients treated (P = 0.0127), female gender (P = 0.0293), minority race (P = 0.0012), less seniority (P = 0.001), and greater COVID-19 prevalence (P = 0.0122). Lower happiness was associated with training country (P = 0.0026), minority race (P = 0.0258) and more seniority (P < 0.0001). Greater depression was associated with more seniority (P < 0.0001). Greater COVID-19 prevalence was associated with greater reported loss of training opportunities (P = 0.0038), poor working conditions (P = 0.0079), personal protective equipment availability (P = 0.0008), relocation to areas of little experience (P < 0.0001), difficulties with career progression (P = 0.0172), loss of supervision (P = 0.0211), difficulties with pay (P = 0.0034), and difficulties with leave (P = 0.0002). CONCLUSION: This is the first study to specifically describe the relative impacts of COVID-19 community prevalence, gender, race, surgical specialty and level of seniority on stress, happiness and depression of surgical trainees on an international scale.

Comparative bibliometric analysis of publications by past Royal Australasian College of Surgeons research scholarship recipients.

BACKGROUND: The Royal Australasian College of Surgeons awards scholarships to surgeons, surgical trainees and recipients focused on developing their clinical knowledge and improving outcomes for patients. A bibliometric analysis of research scholarship recipients publications and h-index scores was conducted to understand the benefits of receiving these scholarships. METHODS: A bibliometric analysis of Royal Australasian College of Surgeons scholarship recipients in 2015 was performed using Open Researcher and Contributor ID (ORCID), Scopus, Google Scholar, ResearchGate, LinkedIn and PubMed to identify the number of publications, h-index scores, field-weighted citation impact and the relative citation ratio. RESULTS: Nineteen research scholarship recipients authored 842 publications, with 491 (58%) published after completion of their scholarship. Seven recipients published 50% or more of their articles in the 5 years since completion. Five recipients have each published more than 45 articles since 2015. H-index scores varied between Scopus and Google Scholar (overall range: 4-34). Scopus identified the most publications, followed by ResearchGate. Determining publication numbers for recipients was problematic due to self-reporting in some databases (i.e. Google Scholar, ResearchGate), variations in author names (i.e. maiden to married name), duplication of publications and the inclusion of supplementary material (i.e. extra tables) in self-reporting databases. Field-weighted citation impact and relative citation ratio values exceeded 1 on 12 occasions demonstrating recipients are more cited than the global average. CONCLUSION: Continuous tracking of publication rates and h-index scores of scholarship recipients demonstrates recipients' continuing interest in advancing and disseminating medical knowledge to improve patient outcomes. The 2015 scholarship recipients publication numbers continued to increase after their scholarship tenure.

Two-year outcomes from the Australian and New Zealand Emergency Laparotomy Audit-Quality Improvement pilot study.

BACKGROUND: The aim of the Australian and New Zealand Emergency Laparotomy Audit-Quality Improvement (ANZELA-QI) pilot study was to determine (i) the outcomes of emergency laparotomy (EL) and (ii) the feasibility of a national, multi-disciplinary quality improvement (QI) project based on a bundle of evidence-based care standards. METHODS: An online database was created using the Research Electronic Data Capture (REDCap) programme. National ethics approval with waiver of consent was obtained. Data were entered directly onto REDCap and extracted monthly for eight care standards (preoperative consultant radiologist reporting of computed tomography scans, preoperative mortality risk score, consultant presence in theatre, timely access to theatre and critical care commensurate with risk and involvement of aged care). Monthly QI run charts using 'traffic' light graphics (green ≥80%, amber ≥50% to <80% and red <50%) reported compliance with the standards. RESULTS: Sixty hospitals indicated interest, but difficulties with site-specific ethics approval resulted in only 24 hospitals participating (2886 EL in 2755 patients). The overall in-hospital mortality was 7.1% (2.3%-13.3%) and average length of stay 15.5 (8.6-22.7) days. Both significantly declined. Preoperative risk assessment (overall 45%) improved almost three-fold during the study. Only 60% had timely access to theatre and only 70% with a predicted mortality risk of >10% were admitted to critical care. CONCLUSION: Overall mortality compared favourably with similar international studies and declined in association with participation in the audit. Compliance with some care standards shows considerable scope to improve EL care using QI methodology.

Telehealth in surgery: an umbrella review.

BACKGROUND: Telehealth use has increased worldwide during the COVID-19 pandemic. However, hands-on requirements of surgical care may have resulted in slower implementation. This umbrella review (review of systematic reviews) evaluated the perceptions, safety and implementation of telehealth services in surgery, and telehealth usage in Australia between 2020 and 2021. METHODS: PubMed was searched from 2015 to 2021 for systematic reviews evaluating real-time telehealth modalities in surgery. Outcomes of interest were patient and provider satisfaction, safety, and barriers and facilitators associated with its use. Study quality was appraised using the AMSTAR 2 tool. A working group of surgeons provided insights into the clinical relevance to telehealth in surgical practice of the evidence collated. RESULTS: From 2025 identified studies, 17 were included, which were of low to moderate risk of bias. Patient and provider satisfaction with telehealth was high. Time savings, decreased healthcare resource use and lower costs were reported as key advantages of the service. Inability to perform comprehensive examinations was noted as the primary barrier. In Australia, peak telehealth usage coincided with the introduction of temporary telehealth services and increased lockdown measures. CONCLUSIONS: Patients and providers are broadly satisfied with telehealth and its benefits. Barriers may be overcome via multidisciplinary collaboration. Telehealth may benefit surgical care long-term if implemented correctly both during and after the COVID-19 pandemic.

Proposed delay for safe surgery after COVID-19.

BACKGROUND: Long-term effects after COVID-19 may affect surgical safety. This study aimed to evaluate the literature and produce evidence-based guidance regarding the period of delay necessary for adequate recovery of patients following COVID-19 infection before undergoing surgery. METHODS: A rapid review was combined with advice from a working group of 10 clinical experts across Australia and New Zealand. MEDLINE, medRxiv and grey literature were searched to 4 October 2020. The level of evidence was stratified according to the National Health and Medical Research Council evidence hierarchy. RESULTS: A total of 1020 records were identified, from which 20 studies (12 peer-reviewed) were included. None were randomized trials. The studies comprised one case-control study (level III-2 evidence), one prospective cohort study (level III-2) and 18 case-series studies (level IV). Follow-up periods containing observable clinical characteristics ranged from 3 to 16 weeks. New or excessive fatigue and breathlessness were the most frequently reported symptoms. SARS-CoV-2 may impact the immune system for multiple months after laboratory confirmation of infection. For patients with past COVID-19 undergoing elective curative surgery for cancer, risks of pulmonary complications and mortality may be lowest at 4 weeks or later after a positive swab. CONCLUSION: After laboratory confirmation of SARS-CoV-2 infection, minor surgery should be delayed for at least 4 weeks and major surgery for 8-12 weeks, if patient outcome is not compromised. Comprehensive preoperative and ongoing assessment must be carried out to ensure optimal clinical decision-making.

Gastrointestinal recovery after surgery: protocol for a systematic review.

INTRODUCTION: Gastrointestinal recovery after surgery is of worldwide significance. Postoperative gastrointestinal dysfunction is multifaceted and known to represent a major source of postoperative morbidity, however, its significance to postoperative care across all surgical procedures is unknown. The complexity of postoperative gastrointestinal recovery is poorly defined within gastrointestinal surgery, and even less so outside this field. To inform the clinical care of surgical patients worldwide, this systematic review and meta-analysis will aim to characterise the duration of postoperative gastrointestinal recovery that can be expected across all surgical procedures and determine the associations between factors that may affect this. METHODS AND ANALYSIS: MEDLINE, Embase, Cochrane Library and CINAHL will be searched for studies reporting the time to first postoperative passage of stool after any surgical procedure. We will screen records, extract data and assess risk of bias in duplicate. Forest plots will be constructed for time to postoperative gastrointestinal recovery, as assessed by various outcome measures. Because of potential heterogeneity, a random-effects model will be used throughout the meta-analysis. Funnel plots will be used to test for publication bias. Meta-regressions will be undertaken where the outcome is the mean time to first postoperative passage of stool, with potential predictors and confounders being patient characteristics, postoperative outcomes and surgical factors. ETHICS AND DISSEMINATION: This study will not involve human or animal subjects and, thus, does not require ethics approval. The outcomes will be disseminated via publication in peer-reviewed scientific journal(s) and presentations at scientific conferences. PROSPERO REGISTRATION NUMBER: CRD42021256210.

ASERNIP-S: unusual acronym, outstanding results.

In the late 1990s, concerns regarding the introduction of new surgical procedures arose following the rapid uptake of some minimally invasive procedures. At that time, the evidence was not clear on the safety and effectiveness of these new procedures, and it was recommended that data be collected to look at both short- and long-term outcomes. Based on a UK group, 'the Safety and Efficacy Register of New Interventional Procedures (SERNIP)', the Australian SERNIP was born under the auspices of the Royal Australasian College of Surgeons, with '-S' added to the acronym to highlight the focus on surgery. ASERNIP-S was established to review the evidence on new interventional procedures before their introduction into the Australian healthcare system. The programme operated with initial national government funding for 7 years. Following establishment of the Medical Services Advisory Committee, ASERNIP-S became a contractor and remains so today. ASERNIP-S was an also an early adopter of Horizon Scanning, a key activity informing of new procedures/technologies on the verge of introduction into our healthcare system. A strong international reputation of ASERNIP-S is recognised, both by lead roles of international networks and in working relationships with overseas agencies. In recent years the remit of ASERNIP-S has expanded to include research and evaluation services across the Royal Australasian College of Surgeons (including committees) and for Specialty Surgical Societies. Externally funded work is growing, including for the Federal Office of Public Health in Switzerland and the Ludwig Boltzmann Institute in Austria. It is unknown what the future will be for this unusually titled programme, but its long history in promoting and supporting surgical evidence and innovation is clear.

Potentially avoidable issues in urology mortality cases in Australia: identification and improvements.

BACKGROUND: This study aimed to identify the most common potentially avoidable factors in urology deaths, focusing on the lessons that can be learnt. METHODS: This study analysed data from a well-established and comprehensive peer review audit of surgical deaths in Australian hospitals (excluding New South Wales) from 2009 to 2015, focusing on urology cases with identified areas for improvement in patient management. Of all audited deaths, 11% (79/719) had serious clinical management issues with a total of 109 individual clinical management issues identified. These were categorized based on perioperative stage (preoperative, intraoperative or post-operative), followed by thematic analysis within each stage. RESULTS: The study found preoperative issues to be the most common (n = 48), followed by post-operative issues (n = 32) with intraoperative issues less common (n = 13). Communication issues were seen at all three stages (n = 16). Overall, the most common theme was at the preoperative stage; inadequate preoperative assessment (n = 27). More specifically, the most common preoperative assessment issues involved a failure to order necessary preoperative investigations, or to administer necessary preoperative treatment (e.g. prophylactic antibiotics). The most common communication issue was between teams and at handover, often involving failure by junior medical staff to communicate issues to the responsible surgical consultant. CONCLUSION: Urological surgical cases with potentially avoidable mortality constitute a small, but important subset of deaths. The analysis of these cases can inform various stakeholders to improve the quality and safety of urological surgical care.

Personal protective equipment and evidence-based advice for surgical departments during COVID-19.

BACKGROUND: Inconsistencies regarding the use of appropriate personal protective equipment (PPE) have raised concerns for the safety of surgical staff during the coronavirus disease 2019 (COVID-19) pandemic. This rapid review synthesizes the literature and includes input from clinical experts to provide evidence-based guidance for surgical services. METHODS: The rapid review comprised of targeted searches in PubMed and grey literature. Pertinent findings were discussed by a working group of clinical experts, and consensus recommendations, consistent with Australian and New Zealand Government guidelines, were formulated. RESULTS: There was a paucity of high-quality primary studies specifically investigating appropriate surgical PPE for healthcare workers treating patients possibly infected with COVID-19. SARS-CoV-2 is capable of aerosol, droplet and fomite transmission, making it essential to augment standard infection control measures with appropriate PPE, especially during surgical emergencies and aerosol-generating procedures. All biological material should be treated a potential source of SARS-COV-2. Staff must have formal training in the use of PPE and should be supervised by a colleague during donning and doffing. Patients with suspected or confirmed COVID-19 should wear a surgical mask during transfer to and from theatre. Potential solutions exist in the literature to extend the use of surgical P2/N95 respirators in situations of limited supply. CONCLUSION: PPE is advised for all high-risk procedures and when a patient's COVID-19 status is unknown. Surgical departments should facilitate staggered rostering, remote meeting attendance, and self-isolation of symptomatic staff. Vulnerable surgical staff should be identified and excluded from operations with a high risk of COVID-19 infection.

Surgery triage during the COVID-19 pandemic.

BACKGROUND: The novel coronavirus, SARS-CoV-2, caused the COVID-19 global pandemic. In response, the Australian and New Zealand governments activated their respective emergency plans and hospital frameworks to deal with the potential increased demand on scarce resources. Surgical triage formed an important part of this response to protect the healthcare system's capacity to respond to COVID-19. METHOD: A rapid review methodology was adapted to search for all levels of evidence on triaging surgery during the current COVID-19 outbreak. Searches were limited to PubMed (inception to 10 April 2020) and supplemented with grey literature searches using the Google search engine. Further, relevant articles were also sourced through the Royal Australasian College of Surgeons COVID-19 Working Group. Recent government advice (May 2020) is also included. RESULTS: This rapid review is a summary of advice from Australian, New Zealand and international speciality groups regarding triaging of surgical cases, as well as the peer-reviewed literature. The key theme across all jurisdictions was to not compromise clinical judgement and to enable individualized, ethical and patient-centred care. The topics reported on include implications of COVID-19 on surgical triage, competing demands on healthcare resources (surgery versus COVID-19 cases), and the low incidence of COVID-19 resulting in a possibility to increase surgical caseloads over time. CONCLUSION: During the COVID-19 pandemic, urgent and emergency surgery must continue. A carefully staged return of elective surgery should align with a decrease in COVID-19 caseload. Combining evidence and expert opinion, schemas and recommendations have been proposed to guide this process in Australia and New Zealand.

Safe surgery during the coronavirus disease 2019 crisis.

BACKGROUND: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has created a global pandemic. Surgical care has been impacted, with concerns raised around surgical safety, especially in terms of laparoscopic versus open surgery. Due to potential aerosol transmission of SARS-CoV-2, precautions during aerosol-generating procedures and production of surgical plume are paramount for the safety of surgical teams. METHODS: A rapid review methodology was used with evidence sourced from PubMed, Departments of Health, surgical colleges and other health authorities. From this, a working group of expert surgeons developed recommendations for surgical safety in the current environment. RESULTS: Pre-operative testing of surgical patients with reverse transcription-polymerase chain reaction does not guarantee lack of infectivity due to a demonstrated false-negative rate of up to 30%. All bodily tissues and fluids should therefore be treated as a potential source of COVID-19 infection during operative management. Caution must be taken, especially when using an energy source that produces surgical plumes, and an appropriate capture device should also be used. Limiting the use of such devices or using lower energy devices is desirable. To reduce perceived risks association with desufflation of pneumoperitoneum during laparoscopic surgery, an appropriate suction irrigator system, attached to a high-efficiency particulate air filter, should be used. Additionally, appropriate use of personal protective equipment by the surgical team is necessary during high-risk aerosol-generating procedures. CONCLUSIONS: As a result of the rapid review, evidence-based guidance has been produced to support safe surgical practice.

Mortality in Australian Cardiothoracic Surgery: Findings From a National Audit.

BACKGROUND: Independent peer review of mortality cases has potential to identify issues in cardiothoracic surgical patients. The Australian and New Zealand Audit of Surgical Mortality aims to improve surgical care through peer-reviewed assessment of all surgical mortality. The aim of this study was to describe common clinical management issues that contribute to patient mortality in a cohort of Australian cardiothoracic surgical patients. This approach may subsequently provide a basis for quality improvement. METHODS: Cardiothoracic mortality reports to the Australian and New Zealand Audit of Surgical Mortality from February 2009 through December 2015 were reviewed. The surgeon report and assessor comments were coded to identify clinical management issues. These were divided into perioperative stages (preoperative, intraoperative, and postoperative), and at each stage a thematic analysis was performed. RESULTS: Of the 908 cases analyzed, 1371 clinical management issues were identified. Postoperative issues were the most common (n = 552), followed by preoperative (n = 378) and intraoperative issues (n = 370). Communication issues were present at all 3 stages (n = 71). Overall the most common theme was intraoperative technical issues (n = 287). Many of these issues revolved around unintentional injury to anatomic structures during surgery and inadequate myocardial protection. Communication issues commonly related to surgical handover to the intensive care unit and lack of shared decision-making. Also common were consultant surgeons being unaware of patient deterioration or significant changes in management. CONCLUSIONS: The Australian and New Zealand Audit of Surgical Mortality provides valuable insights into issues affecting mortality in cardiothoracic patients. Potentially avoidable management issues play a large role in determining the outcome of these patients. Quality improvement initiatives targeting these areas may be valuable.