Evaluation of a modified emergency surgical acuity score in predicting operative and non-operative mortality and morbidity in an acute surgical unit.

BACKGROUND: Emergency general surgery (EGS) patients have an increased risk of mortality and morbidity compared to other surgical patients. Limited risk assessment tools exist for use in both operative and non-operative EGS patients. We assessed the accuracy of a modified Emergency Surgical Acuity Score (mESAS) in EGS patients at our institution. METHODS: A retrospective cohort study from an acute surgical unit at a tertiary referral hospital was performed. Primary endpoints assessed included death before discharge, length of stay (LOS) >5 days and unplanned readmission within 28 days. Operative and non-operative patients were analysed separately. Validation was performed using the area under the receiver operating characteristic (AUROC), Brier score and Hosmer-Lemeshow test. RESULTS: A total of 1763 admissions between March 2018 and June 2021 were included for analysis. The mESAS was an accurate predictor of both death before discharge (AUROC 0.979, Brier score 0.007, Hosmer-Lemeshow P = 0.981) and LOS >5 days (0.787, 0.104, and 0.253, respectively). The mESAS was less accurate in predicting readmission within 28 days (0.639, 0.040, and 0.887, respectively). The mESAS retained its predictive ability for death before discharge and LOS >5 days in the split cohort analysis. CONCLUSION: This study is the first to validate a modified ESAS in a non-operatively managed EGS population internationally and the first to validate the mESAS in Australia. The mESAS accurately predicts death before discharge and prolonged LOS for all EGS patients, providing a highly useful tool for surgeons and EGS units worldwide.

Gastrectomy mortality in Australia.

BACKGROUND: Despite advances in medical management and endoscopic therapy, gastrectomy remains an important yet high-risk procedure for a range of benign and malignant upper gastrointestinal pathologies. No study has previously analysed Australian gastrectomy perioperative mortality rate (POMR). This retrospective, population-based cohort study was conducted to determine the Australian national gastrectomy POMR, allowing state-based and regional trends and outcomes to be assessed. METHODS: Logistic regression models were compared using de-identified procedural data between 1 July 2005 and 30 June 2017 from the Australian Institute of Health and Welfare. Codes relating to total and subtotal gastrectomy contained in the Australian Classification of Health Interventions were used to extract patient data. Mortality rates were risk adjusted for age and gender. Temporal trends and differences between states/territories and regions were investigated. RESULTS: The national average POMR throughout the study period was 2.1%. For subtotal gastrectomy, the national mean POMR was 1.1%, decreasing from 2.7% (2005) to 1.3% (2017). For total gastrectomy, the national mean POMR was 2.8%, decreasing from 3.3% (2005) to 1.7% (2017). POMR significantly reduced over time without variation between states or regions. Procedure volume steadily reduced in rural centres with a concomitant increase in metropolitan centres over time. CONCLUSION: Pleasingly, the Australian gastrectomy POMR is favourable when compared to international cohorts. Improved outcomes were consistent between states and territories, and metropolitan and regional centres. Progressive metropolitan centralization of gastrectomy was demonstrated without evidence of improved outcomes.

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.

Regional versus metropolitan pancreaticoduodenectomy mortality in Australia.

BACKGROUND: This retrospective, population-based cohort study aims to determine if differences in the regional distribution of procedures or variation in regional mortality contributes to the variable pancreaticoduodenectomy (PD) mortality between Australian states and territories. METHODS: De-identified procedural data from public hospitals between 1 July 2005 and 30 June 2015 from the Australian Institute of Health and Welfare were analysed. The regional distribution of procedures and variation in perioperative mortality rate (POMR) were investigated in New South Wales (NSW), Victoria and Queensland (QLD) using logistic regression analysis. RESULTS: NSW performed the highest proportion of city-based procedures (93.8%) while QLD performed the highest proportion of regional procedures (15.3%). QLD demonstrated the lowest city mortality (1.9%) and lowest POMR overall (2.0%). City, regional and state-wide mortality was highest in NSW (5.0%, 8.4% and 5.3%). No significant difference in POMR was demonstrated between regional and city hospitals in each of the states (P = 0.46) or across all states (P = 0.50). CONCLUSION: This study demonstrates comparable regional PD distribution across Australia. The difference in PD POMR between city and regional areas was not found to be statistically significant. NSW exhibited the highest city, regional and overall PD POMR, potentially warranting further investigation.

Fatal flaws in clinical decision making.

BACKGROUND: Clinical decision making is a core competency of surgical practice, involving a continuous and evolving process of data interpretation and evaluation. The aim of this article is twofold. First, to recognize patient deaths where a clinical incident arose following unsatisfactory clinical decision making, determining where in the clinical decision-making process each failure occurred. Second, to discuss and explore individual incidents to provide lessons from which the surgical community can learn. METHODS: Using the Australian and New Zealand Audit of Surgical Mortality database, all deaths from 1 January 2015 to 31 December 2015 were analysed. All deaths in which the surgeon or assessor identified an aspect of patient management that was inadequate were recognized. Clinical incidents deemed by the assessor to be an area of concern or an adverse event were individually reviewed to determine if a clinical decision-making incident (CDMI) occurred. CDMIs were categorized into various themes depending on the nature of the incident. RESULTS: A total of 3422 fully audited deaths occurred throughout the study period; from these cases, 226 individual CDMIs were identified. Decision to operate was the most commonly identified CDMI (n = 99, 43.8%), followed by diagnostic error (n = 49, 21.7%). The least common CDMI identified was inadequate post-operative assessment (n = 14, 6.2%). CONCLUSION: This paper demonstrates thought-provoking examples of clinical decision-making failure implicated in patient death. Clinical decision-making failures most commonly occur around the decision to operate with increased discussion of complex cases possibly required. Further CDMI evaluation should be considered to complement more traditional methods of surgical mortality evaluation.

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.