Medical versus surgical causes of death following colorectal resection: a Queensland Audit of Surgical Mortality (QASM) study.

BACKGROUND: The causes of death following colorectal resection remain poorly explored. Few studies have addressed whether early post-operative mortality is predominantly caused by a patient's medical co-morbidities, or from factors pertaining to the presenting surgical disease process itself. This study analyses data from the Queensland audit of surgical mortality (QASM) to report the causes of in-hospital death following colorectal resection, identifies whether these were due to either medical or surgical factors, and determines the patient characteristics associated with a medical cause of death. METHODS: Through analysis of QASM Surgical Case Forms, the causes of in-hospital death were determined in 750 patients who died in Queensland following colorectal resection between January 2010 and December 2020. Deaths were attributed to a specific medical or surgical cause, with multivariate analysis used to identify independent risk factors associated with a medical cause of death. RESULTS: In total, 395 patients (52.7%) died due to surgical causes and 355 (47.3%) died due to medical causes. Respiratory co-morbidities (OR 1.832, 95% CI: 1.267-2.650), advanced malignancy (OR 1.814, 95% CI: 1.262-2.607), neurological co-morbidities (OR 1.794, 95% CI: 1.168-2.757) and advanced age (OR 1.430, 95% CI: 1.013-2.017) were independent risk factors associated with increased risk of a medical cause of death. CONCLUSION: Even in the absence of complicating surgical factors, a significant number of patients died in hospital following colorectal resection due to their underlying co-morbidities. Multi-disciplinary models of care which allow for the early recognition and treatment of medical complications may reduce post-operative mortality in these patients.

Critical Analysis of the Causes of In-Hospital Mortality following Colorectal Resection: A Queensland Audit of Surgical Mortality (QASM) Registry Study.

BACKGROUND: Colorectal resection is a major gastrointestinal operation. Improvements in peri-operative care has led to improved outcomes; however, mortalities still occur. Using data from the Queensland Audit of Surgical Mortality (QASM), this study examines the demographic and clinical characteristics of patients who died in hospital following colorectal resection, and also reports the primary cause of death in this population. METHODS: Patients who died in hospital following colorectal resection in Queensland between January 2010 and December 2020 were identified from the QASM database. RESULTS: There were 755 patients who died in the 10 year study period. Pre-operatively, the risk of death as subjectively determined by operating surgeons was 'considerable' in 397 cases (53.0%) and 'expected' in 90 cases (12.0%). The patients had a mean of 2.7 (±1.5) co-morbidities, and a mean American Society of Anaesthesiologists (ASA) score of 3.6 (±0.8). Operations were categorised as emergency in 579 patients (77.2%), with 637 patients (85.0%) requiring post-operative Intensive Care Unit (ICU) support. The primary cause of death was related to a surgical cause in 395 patients (52.7%) and to a medical cause in 355 patients (47.3%). The primary causes of death were advanced surgical pathology (n=292, 38.9%), complications from surgery (n=103, 13.7%), complications arising from pre-existing medical co-morbidity (n=282, 37.6%) or new medical complications unrelated to pre-existing conditions (n=73, 9.7%). CONCLUSIONS: Patients who died had significant co-morbidities and often presented emergently with an advanced surgical pathology. Surgical and medical causes of death both contributed equally to the mortality burden.

The associations of factors with previous alcohol use in the Northern Territory compared to other states - an observational study.

BACKGROUND: Data on previous alcohol use in surgical patients who died in the Northern Territory (NT) are lacking and have important public health implications. METHODS: The prevalence of previous alcohol (ab)use among surgical patients who died (n=560) was assessed in patients within the Northern Territory and the remainder of Australia (n=28,245) over nine years. RESULTS: The likelihood of previous alcohol use (21.4%; 120 of 560), was the outcome measured and was higher in the Northern Territory than outside it (5.9%; 1,660 of 28,245). Factors associated with the outcome of previous alcohol use were: male gender (aOR 1.6); Aboriginal and Torres Strait Islander status (aOR 2.0); liver disease (aOR 7.8); comorbidities (aOR 2.5); and trauma (aOR 1.1), in both the Northern Territory (aOR 11.5) and all Australia (aOR 7.8). In the Northern Territory, alcohol use was high in both Aboriginal and Torres Strait Islander people (31%) and non-Aboriginal and Torres Strait Islander (16%) people (p=0.316). CONCLUSION: Of surgical patients who died, the likelihood of being a previous alcohol user was double in the Northern Territory as opposed to other states. Alcohol misuse is widespread across all groups in the Northern Territory. Implications for public health: Previous alcohol (ab)use is a negative factor for survival in any racial group.

Surgeons' Responses to a Surgical Mortality Audit: Accepting and Improving: A Cross Sectional Survey.

BACKGROUND: Surgeons strive to provide the best care possible to their patients. The Australian and New Zealand Audit of Surgical Mortality is a process for improving surgical care and outcomes via peer-review assessment of mortality cases. This article examines the acceptability of the assessments to Queensland surgeons, in addition to examining their impact on surgical care. METHODS: This study was a cross-sectional survey. Evaluation forms were sent to all Queensland surgeons who had received a first-line assessment with clinical incidents identified or a second-line assessment (with or without clinical incidents), between April 2018 and January 2020 (n = 484). A total of 102 evaluation forms were returned, giving a response rate of 21%. RESULTS: Most respondents agreed that their assessments were fair (78%) and informative (69%). Almost half (43%) agreed that their assessment improved the subsequent surgical care they provided. Comments supported this, with surgeons describing reflections, meetings and changes that had occurred following their assessments. Despite the strong proportion of positive comments, some surgeons disagreed with the opinions or recommendations of their assessors. A large percentage (41%) was neutral towards the ability of the assessments they had received to improve surgical care at the hospital level. CONCLUSIONS: There was a high degree of acceptance of the QASM peer-review assessment process. The assessments facilitated discussion, reflection and implementation of surgical care improvements in Queensland surgeons. Further research into this topic should involve refinement of the study tool with a larger, and therefore more representative, proportion of the surgical population.

Snapshot of trauma laparotomy deaths in Queensland.

BACKGROUND: Trauma remains the most frequent cause of death for patients under 35 years of age. Head injury and catastrophic haemorrhage account for the majority of early deaths. A trauma laparotomy is often necessary to arrest haemorrhage. METHODS: All patients who died in Queensland hospitals between 2011 and 2016 having had a trauma laparotomy were identified from the Queensland Audit of Surgical Mortality. RESULTS: About 69.0% of the 84 deaths were male with a median age of 47.6 years. About 64.3% of deaths occurred within the first 2 days following trauma. Mechanism of injury was typically road traffic accident (77.4%). Sixteen patients underwent a non-therapeutic laparotomy. Following peer-review, different management was recommended for only three patients. CONCLUSION: This group of patients who died in the setting of a trauma laparotomy received high quality trauma care. Ongoing education is needed as some non-therapeutic laparotomies may be avoidable.

How participation in surgical mortality audit impacts surgical practice.

BACKGROUND: Surgical mortality audit is an important tool for quality assurance and professional development but little is known about the impact of such activity on professional practice at the individual surgeon level. This paper reports the findings of a survey conducted with a self-selected cohort of surgeons in Queensland, Australia, on their experience of participating in the audit and its impact on their professional practice, as well as implications for hospital systems. METHODS: The study used a descriptive cross-sectional survey design. All surgeons registered in Queensland in 2015 (n = 919) were invited to complete an anonymous online questionnaire between September and October 2015. 184 surgeons completed and returned the questionnaire at a response rate of 20%. RESULTS: Thirty-nine percent of the participants reported that involvement in the audit process affected their clinical practice. This was particularly the case for surgeons whose participation included being an assessor. Thirteen percent of the participants had perceived improvement to hospital practices or advancement in patient care and safety as a result of audit recommendations. Analysis of the open-ended responses suggested the audit experience had led surgeons to become more cautious, reflective in action and with increased confidence in best practice, and recognise the importance of effective communication and clear documentation. CONCLUSIONS: This is the first study to examine the impact of participation in a mortality audit process on the professional practice of surgeons. The findings offer evidence for surgical mortality audit as an effective strategy for continuous professional development and for improving patient safety initiatives.

Clinical events reported by surgeons assessing their peers.

BACKGROUND: All surgical deaths in Queensland, Australia are reviewed by external surgeon peers, and clinical events are recorded. The study objective was to classify clinical events in surgical patients who died. METHODS: Deaths notified to the Queensland Audit of Surgical Mortality between 2007 and 2013 were assessed by surgeons' peers who decided whether a clinical event occurred. The most serious clinical event per patient was analyzed. RESULTS: Peer surgeons reviewed 4,816 deaths. Most patients (70.7%) had no clinical event. Events were preventable in 58% of patients and less than 1 in 10 events was severe. The most frequent events were classified as patient assessment (34.5%), suboptimal therapy (15.3%), and delays (15.1%). CONCLUSIONS: Peer review of all surgical deaths identifies preventable clinical events and provides opportunities to improve decision making, better therapy and reduce delay in implementing appropriate surgical care. Review feedback to surgeons and other stakeholders should improve patient safety and quality.

Surgical mortality audit data validity.

BACKGROUND: Surgical audits provide constructive feedback to individual surgeons, hospitals and other healthcare sector professionals. Audits identify deficiencies in treatment processes, evaluate practice trends and detect practice gaps. The credibility and validity of the Queensland Audit of Surgical Mortality (QASM) relies on the accuracy of its data. METHODS: To determine the validity of routine reporting of surgical information to QASM, surgical case forms were compared against medical records (considered the gold standard). Data were extracted by a trained medical research assistant. QASM forensically reviewed 896 of a total of 5636 deaths in 20 Queensland public hospitals between 2008 and 2013. Concordance between the surgical case form and the relevant medical record was determined for 27 objective items. RESULTS: Overall concordance was 98.2%. The median concordance was 100% (interquartile range 87-100%). Cases with discordance were few and in these, most had only one discordant item. Discordances were mainly omissions. CONCLUSION: The QASM surgical case form is a reliable data collection tool that provides high-quality data. QASM objective data can be confidently regarded as accurate and therefore reliable for use in publications, reports and case studies.

Surgical care for the aged: a retrospective cross-sectional study of a national surgical mortality audit.

OBJECTIVES: It is assumed that increased age signifies increased surgical care. Few surgical studies describe the differences in care provided to older patients compared with younger patients. We aimed to examine the relationships between increasing age, preoperative factors and markers of postoperative care in adults who died in-hospital after surgery in Australia. DESIGN: This retrospective cross-sectional study extracted data from a national surgical mortality audit--an independent, peer-reviewed process. SETTING: From January 2009 to December 2012, 111 public and 61 private Australian hospitals notified the audit of in-hospital deaths after general anaesthetic surgery or if the patient was admitted under a surgeon. PARTICIPANTS: Notified deaths totalled 19,723. We excluded deaths if patients were brain dead, younger than 17 years or never had an operation (n=11,376). From this baseline population, we divided 11,201 deaths into three patient age groups: youngest (17-64 years), medium (65-79 years) and oldest (≥80 years). OUTCOME MEASURES: Univariable and multivariable logistic regression analyses determined the relationships between increasing age and the measured preoperative factors and postoperative variables. RESULTS: The baseline population's median age was 78 years (IQR 66-85), 43.7% (4892/11,201) were 80 years or older and 83.4% (9319/11,173) had emergency admissions. The oldest group had increased trauma and emergency admissions than the medium and youngest age groups. Seven of the eight measured markers of postoperative care demonstrate strong and significant relationships with increasing age. The oldest group compared with the medium group had decreased rates of: unplanned returns to theatre (11.2% (526/4709) vs 20.2% (726/3586)), unplanned intensive care admissions (16.3% (545/3350) vs 24.0% (601/2504)) and treatment in intensive care units (59.7% (2689/4507) vs 76.7% (2754/3590)). CONCLUSIONS: The oldest patients received lower levels of care than the medium and youngest age groups.

Mortality from acute appendicitis is associated with complex disease and co-morbidity.

BACKGROUND: Studies evaluating mortality in patients with acute appendicitis focus on the outcomes of appendicectomy alone. We hypothesize this may not be representative of what happens in clinical practice as a small proportion of patients with acute appendicitis undergo procedures other than appendicectomy, for example, caecectomy or right hemicolectomy. To clarify the issue, the authors evaluated Australian adult patients who died with a primary diagnosis of acute appendicitis regardless of whether they underwent an operation or the type of operation performed. METHODS: A cross-sectional analysis of systematically collected mortality data from the Australian and New Zealand Audit of Surgical Mortality was conducted on adults who died in hospital with a primary diagnosis of acute appendicitis between January 2009 and December 2012. RESULTS: Twenty-six patients died with a primary diagnosis of acute appendicitis. The median age was 83 years and the median number of co-morbidities was three. Four patients died without surgery due to their family's wishes. Twenty-two patients were treated surgically: five for right hemicolectomy, four for laparoscopic/McBurney appendicectomy, 10 for laparotomy with appendicectomy, two for unknown method of appendicectomy and one for open abscess drainage. CONCLUSION: Most adult patients who died following surgery for acute appendicitis did not undergo simple appendicectomy but underwent more complicated procedures for complex appendicitis.

Outcomes from the Northern Territory Audit of Surgical Mortality: Aboriginal deaths.

BACKGROUND: A significant 'gap' in life expectancy exists for Australian Aboriginal people. The role of surgical care in this gap has been poorly addressed. This study has compared in-hospital surgical deaths of Aboriginal and non-Aboriginal persons in order to identify patient factors plus deficiencies of care that may have contributed to the gap. METHODS: This study used retrospective data collection and prospective audit of all in-hospital surgical deaths since commencement of the Northern Territory Audit of Surgical Mortality (NTASM). Outcome measures included causes of death, coexisting factors and deficiencies of care. RESULTS: Between June 2010 and June 2013, 190 deaths were audited (96% capture), of which 72 (38%) were Aboriginal. Aboriginal persons were younger at death (53 versus 65 years, P < 0.001) and had a higher incidence of diabetes (odds ratio = 2.8, 95% confidence interval: 1.4-5.6), renal (2.3, 1.1-4.7) and liver disease (5.7, 2.6-12.9). When adjusted for age and gender, serious cofactors were significantly more common in Aboriginal persons (3.8, 1.3-7.1). Rates of infections and all-cause trauma were comparable. There were no significant differences in the rates of complications, unplanned returns to theatre or intensive care unit, delays to surgery or whether in retrospect the surgeon considered management overall could have been improved. CONCLUSIONS: A large gap of 12 years exists for age at death between Aboriginal and non-Aboriginal persons admitted as surgical patients in the Northern Territory. Aboriginal persons had significantly more co-morbidities at time of death, particularly diabetes, renal and hepatic disease. No significant discrepancies of surgical care were identified between Aboriginal and non-Aboriginal persons.

Parental Concerns about the Health of Adolescents with Intellectual Disability: A Brief Report.

Background. Parents of adolescents with intellectual disability are concerned about the future health and well-being needs of their children. Method. Qualitative data was collected as part of a cross-sectional descriptive study and semi-structured interviews were conducted with 32 parents. The results were themed. Results. Most parents discussed areas of their children's health which made them anxious about the future. These concerns were collated into five themes. Conclusion. The health and well-being themes were dependency, general health, challenging behaviours, and increasing support needs.

Psychiatric care of adults with intellectual disabilities: changing perceptions over a decade.

OBJECTIVE: In light of developments in training and service provision, the aim of the present study was to compare two state-wide surveys, undertaken in 1994 and in 2004, of psychiatrists about their perceptions of their training and psychiatric treatment of adults with intellectual disabilities who also have mental health needs. METHODS: A 50-item self-administered questionnaire was developed for the 2004 survey, based on the 1994 study. This was sent to all 624 Fellows of the Royal Australian and New Zealand College of Psychiatry registered in Victoria at the time. A series of questions was asked based on workload, training, the role of psychiatry in intellectual disabilities, opinions on assessment and management, improving services, and the demographics of participant psychiatrists. Results of the 2004 survey are compared with the 1994 study. RESULTS: There has been some change in psychiatrists' opinions about acute admission wards, believing strongly that they do not meet the needs of the adults with severe intellectual disabilities, leaving them vulnerable to exploitation. There has been some improvement in their ability to adequately manage adults with intellectual disabilities who have mental health needs and/or problem behaviours. CONCLUSIONS: Mainstream mental health services fail to meet the needs of adults with intellectual disabilities. Improved specialist clinical services and more clinical training opportunities are required.

Effects of a comprehensive health assessment programme for Australian adults with intellectual disability: a cluster randomized trial.

BACKGROUND: People with intellectual disability constitute approximately 2% of the population. They die prematurely, and often have a number of unrecognized or poorly managed medical conditions as well as inadequate health promotion and disease prevention. METHODS: A cluster randomized controlled trial with matched pairs was carried out. The participants were adults with intellectual disability (n = 453 in 34 clusters). The intervention was a health assessment programme to enhance interactions between the adult with intellectual disability, their carer and their general practitioner (GP). It prompted the systematic gathering of a health history and, subsequently, access to a GP for a guided health review and development of a health action plan. It also provided information about the health of adults with intellectual disability. Follow-up was for 1 year post intervention, with outcomes extracted from GPs' clinical records. RESULTS: Increased health promotion, disease prevention and case-finding activity was found in the intervention group. Compared with the control group there was a 6.6-fold increase in detection of vision impairment (95% confidence interval 1.9-40); a 30-fold increase in hearing testing (4.0-230); an increase in immunization updates [tetanus/diphtheria a 9-fold increase (4.2-19)], and improvements in women's health screening [Papanicolau smears were eight times more common (1.8-35)]. The intervention increased detection of new disease by 1.6 times (0.9-2.8). CONCLUSIONS: The Comprehensive Health Assessment Program (CHAP) produced a substantial increase in GPs' attention to the health needs of adults with intellectual disability with concomitantly more disease detection. The presumption that these will yield longer-term health benefits, while suggestive, remains unexamined.

ask for it: development of a health advocacy intervention for adults with intellectual disability and their general practitioners.

Two per cent of people in Australia have intellectual disability and the adults in this population often have poor health status. This poor health can be partly attributed to communication difficulties encountered by people with intellectual disability and also health professionals in consultation settings. The design and development processes of an educational intervention to improve communication between patients, general practitioners (GPs) and also advocates in a population of adults with intellectual disability are described. The design process was collaborative and involved adults with intellectual disability, GPs, parents, support workers and other professionals. It was a nine-step development process and led to the final communication tool package, the ask (advocacy skills kit) 5-year health diary and educational session. As a result of the collaborative design and development processes, this diary included qualities not found in most other medical record keeping systems: visual appeal, advice on how to be a health advocate, utility for a range of users, privacy, portability and sufficient capacity to record personal patient information which enhanced communication between doctor, patient and advocate. It is proving to be very popular. Clear implications were found for applying established criteria and incorporating the needs of users in the design of educational interventions in the intellectually disabled population. Health promotion tools aiming to improve the current poor health status of adults with intellectual disability should be developed further.