Providers and consumers support the Western Australian Audit of Surgical Mortality

BACKGROUND: The Western Australian Audit of Surgical Mortality (WAASM) was established in June 2001 to independently peer-review all surgical deaths in Western Australia. The objectives of this study were (i) to evaluate whether participation in the WAASM has influenced clinical and hospital practice; and (ii) to ascertain the support and relevance of the WAASM to surgeons, hospitals and consumers. METHODS: Three qualitative questionnaires were designed to evaluate the response of surgeons, hospital administrators and consumers to the WAASM. The outcomes measured included audit participation, value and use of feedback provided, changes to clinical and hospital practice and the future role of the WAASM. RESULTS: The key findings were that 138 (73%) of 190 surgeons participating in the WAASM had changed their clinical practice in at least one way, 44 (24%) were aware of changes in hospital practice and 21 (11%) were aware of changes in a colleague's practice. Particular areas where changes in surgical practice had occurred included attention to deep vein thrombosis prophylaxis (81, 44%), increased constructive discussion among peers (78, 42%) and quality of documentation in case notes (68, 37%). All groups supported the continuation of the WAASM. Hospital executives and consumers recommended that the WAASM be included in accreditation. CONCLUSION: Surgeons, hospitals and consumers supported the concept of independent peer review of surgical care. They confirmed the ability of audit to influence and change surgical and hospital practice. It strengthens the intention of the Royal Australasian College of Surgeons to extend the WAASM project throughout Australia and New Zealand.     

Measuring clinical audit and peer review practice in a diverse health care setting

Background: A measurement system was devised to determine the extent of clinical audit and peer review across the Hunter Area Health Service, to compare changes over time and to assess the effect of the implementation of a policy on the conduct of patient safety meetings. Methods: Two surveys were conducted over consecutive years (2001, 2002). A scoring system was developed based on a 12 point questionnaire. Ten points were given for a ‘yes’ response and zero for a ‘no’ response. Points were also given for frequency of meetings. Statistical analysis was by the Mann?Whitney U‐test. The questionnaire included items on clinical indicators, management of issues arising and whether meetings are multidisciplinary, chaired and points for action minuted and followed up. Results: One‐hundred and five units provided data for the 2001 survey (100% response rate) and 109 units provided data for the 2002 survey (100% response rate). There was a significant increase in the median score in the 2002 survey (median 101; interquartile range 72?113) when compared with the 2001 Survey (median 91; interquartile range 51?110; P = 0.016). There was an improvement of 9% in units scoring in the highest quartile (90?120 points) and a decrease of 5% in units scoring in the lowest quartile (0?29 points). Conclusions: This methodology allows for the quantitative measurement of audit and peer review activities across clinical units. It might assist clinicians, professional colleges and departments of health in the further development of the recertification\revalidation process.     

Clinical governance: its effect on surgery and the surgeon

Audit is the process by which clinical staff collectively review, evaluate and improve their clinical practice with the common aim of improving standards. Modern audit has developed from the initial concept promoted in the 1980s and is now part of the concept of clinical governance. Clinical governance is a framework through which health service organizations are accountable for continuously improving the quality of their services. Clinicians have always been accountable for maintaining high quality care; clinical governance merely imposes structure in this and makes it explicit. The features of this are: (i) full participation in audit by all hospital doctors; (ii) support and use evidence-based practice, including risk management, quality assurance and clinical effectiveness; and (iii) continuing professional development.     

Analysis of potential clinical management issues in unreported mortality data from an Australian health service

Background

We have previously reported incomplete data submission to the Victorian Audit of Surgical Mortality (VASM) by a large health service. We have further examined the source health service clinical data to assess whether any clinical management issues (CMI) occurred and should have been reported.

Methods

The previous study identified 46 deaths that should have been reported to VASM. The hospital records of these patients were further analysed. Data recorded included the patient's age, gender, admission type and clinical course. Any potential clinical management issues were recorded and classified using the VASM definitions (area of consideration or concern, adverse event).

Results

Median age of the deceased patients was 72 (range 17–94), with 17 (37%) being female. Patients were under the care of nine different specialties with general surgery being the most common (18/46). Only four (8.7%) of the cases were electively admitted. 17 (37%) patients had at least one CMI with 10 (21.7%) classified as adverse events. Most deaths were not considered preventable.

Conclusion

The proportion of CMI in the unreported deaths was consistent with the previously reported VASM data, however current findings show a high percentage of adverse events. The underreporting may be due to inexperienced medical staff or coders, poor quality notes or confusion about what should be reported. These findings reinforce the importance of data collection and reporting at the health service level, and a number of important lessons and opportunities to improve patient safety have been lost.     

Provisional unicentric experience with an electronic incident reporting form in pediatric anesthesia

Objective: To present and compare with literature our experience with an electronic anesthesia‐related incident reporting form as a quality control measure at Gaslini Children’s Hospital over a 19‐month period. Methods: All events that occurred between March 2009 and September 2010 were recorded. We adopted an electronic reporting form included in the online recording process of every anesthetic procedure. Events were divided into near misses and adverse events. Adverse events were further divided into incidents, minor events, and major events. Patients were divided into three age‐groups: <1, between 1 and 3, and >3 years. Results: A total of 12 850 anesthetics were performed. Eight (0.06%) near misses and 108 (0.8%) adverse events were reported. Adverse events occurred more frequently in infants. Of 108 events, 35 (32.4%), 61 (56.5%), and 12 (11.1%) were classified as incidents, minor, and major events, respectively. Of all the adverse events, 66 (61%) were respiratory, 27 (25%) organizational, six (5%) drug‐related, four (4%) cardiocirculatory, and five (5%) miscellaneous. Conclusions: Infants were at the highest risk to experience adverse events. Although experimental electronic incident reporting proved to be feasible, there is reason to suspect that there was underreporting of near misses. Overreporting of near miss events may be enhanced by easier and more straightforward reporting forms as well as by better education for anesthetic providers about the importance of recognizing and reporting near misses.     

Major incident triage: A consensus based definition of the essential life-saving interventions during the definitive care phase of a major incident

IntroductionTriage is a key principle in the effective management of major incidents. The process currently relies on algorithms assigning patients to specific triage categories; there is, however, little guidance as to what these categories represent. Previously, these algorithms were validated against injury severity scores, but it is accepted now that the need for life-saving intervention is a more important outcome. However, the definition of a life-saving intervention is unclear. The aim of this study was to define what constitutes a life-saving intervention, in order to facilitate the definition of an adult priority one patient during the definitive care phase of a major incident.MethodsWe conducted a modified Delphi study, using a panel of subject matter experts drawn from the United Kingdom and Republic of South Africa with a background in Emergency Care or Major Incident Management. The study was conducted using an online survey tool, over three rounds between July and December 2013. A four point Likert scale was used to seek consensus for 50 possible interventions, with a consensus level set at 70%.Results24 participants completed all three rounds of the Delphi, with 32 life-saving interventions reaching consensus.ConclusionsThis study provides a consensus definition of what constitutes a life-saving intervention in the context of an adult, priority one patient during the definitive care phase of a major incident. The definition will contribute to further research into major incident triage, specifically in terms of validation of an adult major incident triage tool.     

Critical analysis of clinical research reporting in pediatric surgery: justifying the need for a new standard

Background/Purpose: Clinical practice in surgery relies heavily on observational data in which accurate and nonbiased reporting is critical. This study aims to assess the adequacy of clinical research reporting in pediatric surgery and to develop a means to raise the standard of such reporting.Methods: The authors analyzed all observational studies published in The Journal of Pediatric Surgery from 1997 to 2002 (n = 300). Studies were assessed for 16 baseline criteria essential for the nonbiased reporting of clinical data (details regarding surgeons, cases, interventions, and statistical methods). Seven additional criteria pertaining to comparison methods were assessed in studies using controls.Results: Ninety-five percent of all studies were retrospective, and only 25% utilized a control group. Most studies met less than half of the essential reporting criteria (mean, 7.6 of 16 baseline criteria; 3.3 of 7 comparison criteria). Reporting deficiencies were found in all major aspects of study design and statistical analysis.Conclusions: More rigorous reporting of clinical data in pediatric surgery could increase the clinical utility of published results. The authors have identified the fundamental elements essential to nonbiased reporting of clinical research data in surgery. Implementation of mandatory peer-review guidelines based on these principles could set a new standard for clinical reporting in surgery.     

临床护士不良事件风险感知与报告习惯的调查

目的探讨临床护士不良事件风险感知、不良事件报告习惯的状况及两者关系。方法采用护理不良事件风险感知结构维度量表和临床护士不良事件报告习惯问卷,对泰安市10所综合医院917名临床护士进行问卷调查。结果临床护士不良事件风险感知得分为16.48±3.79;临床护士不良事件报告习惯得分为36.80±19.71;患者照护风险感知对护士不良事件报告习惯具有预测性(P0.05)。结论临床护士不良事件风险感知与报告习惯有待提高,不良事件风险感知对其报告习惯有影响。可通过增强临床护士不良事件风险感知意识和能力来提高护士不良事件报告行为,以更好地提高患者安全管理水平,降低不良事件的发生。     

Evaluation of the P-POSSUM mortality prediction algorithm in Australian surgical intensive care unit patients

Background: The Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (POSSUM) is an auditing tool designed to compare surgical outcomes independent of case mix. It uses patient physiological and operative data to predict morbidity and mortality for surgical patients. Thus far most evaluations of the POSSUM algorithm and its modifications have emanated from British hospitals. A single‐centre retrospective study was therefore performed to determine the applicability of this tool to the Australian surgical case mix. Methods: All surgical patients undergoing a surgical procedure admitted to the Royal Brisbane Hospital intensive care facility in 1999 were reviewed retrospectively. Mortality predictions using the Portsmouth modification of the POSSUM algorithm (P?­POSSUM) were compared to the actual outcomes using receiver‐operator characteristic curve analysis and the Hosmer and Lemeshow Goodness‐of‐Fit test. Results: The records of 229 admissions were reviewed. The area under the receiver‐operator characteristic curve was 0.68, significantly greater than 0.5 (P = 0.014). Predicted deaths were significantly greater than actual deaths (50 vs 28, P < 0.001), with over‐prediction of death rates in all mortality groupings except the two lowest risk deciles. Conclusion: The P?POSSUM algorithm tends to over‐estimate mortality in surgical intensive care patients. It may require further calibration before adoption as a surgical audit tool in Australia.     

Perioperative anaesthetic morbidity in children: a database of 24,165 anaesthetics over a 30-month period

BACKGROUND: This study reports the practices and morbidity of 24,165 anaesthetics performed over a 30-month period in a paediatric teaching hospital. METHODS: Data describing practices and adverse events during anaesthesia and in the postanaesthesia care unit (PACU) were collected prospectively from 1 January 2000 to 30 June 2002 on an audit form as a part of the Quality Assurance Program. All surgical specialties are covered except for open heart surgery and neurosurgery. RESULTS: A total of 724 adverse events were reported during anaesthesia and 1105 in PACU. Respiratory events represented 53% of all intraoperative events. They were more frequent in infants compared with older children, in ENT surgery compared with other surgery, in children in whom the trachea was intubated and in children with ASA status 3-5 compared with those with ASA score 1 or 2. Cardiac events accounted for 12.5% of intraoperative events and were mainly observed in children with ASA score 3-5. In PACU, vomiting was the most frequent adverse event with an overall incidence of 6%. Vomiting was more frequent in older children compared with infants and young children and more frequent after ENT surgery compared with other surgery. Only one death was reported in a premature newborn infant and was not anaesthesia-related. CONCLUSIONS: This observational study confirms previous reports, and indicates that there is still a relative higher rate of adverse events in infants compared with older children even in a teaching paediatric hospital with a high annual caseload.     

基于临床知识库的智能学习型不良事件管理系统的构建与应用

目的 构建基于临床知识库的智能学习型不良事件管理系统并评价其应用效果。方法 组建研发小组,构建智能学习型不良事件管理系统,包括不良事件原因分析及对策措施知识库,以及事件上报、分析、整改、分享、数据统计分析5个模块,结合试点病区医务人员反馈的改进需求对系统进行优化后正式上线。结果 系统应用前后不良事件发生率分别为0.68‰、0.72‰;系统应用后不良事件引发的投诉率由16.85%降低至12.04%,流程改进数量由28个增加至43个;医务人员对医院患者安全文化同意率除组织学习与持续改进、对患者安全的管理支持两个维度外,其他10个维度显著提高（均P＜0.05）。结论 基于临床知识库的智能学习型不良事件管理系统能为不良事件管理提供精准的决策支持,促进不良事件管理的规范化,增强医院患者安全文化氛围,进一步保障了患者安全。     

Evolution of trends in risk management

In the past, the detection and response to adverse clinical events were viewed as an inherent part of professionalism; and, if perceived problems were not sorted out at that level, the ultimate expression of dissatisfaction was litigation. There are now demands for the adoption of more transparent and effective processes for risk management. Reviews of surgical practice have highlighted the presence of unacceptable levels of avoidable adverse events. This is being resolved in two ways. First, attention is being directed to the extent that training and experience have on outcomes after surgery, and both appear to be important. Second, a greater appreciation of human factors engineering has promoted a greater involvement of surgeons in processes involving teamwork and non-technical skills. The community wants surgeons who are competent and health-care systems that minimize risk. In recent times attention has been focused on the turmoil associated with change; but, when events are viewed over a period of several decades, there has been considerable progress towards these ideals. Further advancement would be aided by removing the adversarial nature of malpractice systems that have failed to maintain standards.     

心理安全感与主动性行为在差错管理氛围与患者安全胜任力间的中介作用

目的 探究心理安全感与主动性行为在差错管理氛围与患者安全胜任力间的中介作用,为针对性管理提供参考。方法 采用便利抽样方法选取782名临床护士为研究对象。使用一般资料调查表、差错管理氛围量表、心理安全感量表、主动性行为绩效测评量表、患者安全胜任力护理人员自评量表进行调查。结果 护士感知的差错管理氛围、心理安全感、主动性行为及患者安全胜任力得分分别为（70.28±11.93）分、（61.21±13.44）分、（37.60±7.33）分、（121.31±19.51）分。不同职称、学历和工作科室的护士,其患者安全胜任力得分差异有统计学意义（均P＜0.05）。心理安全感与主动性行为是差错管理氛围与患者安全胜任力间的中介变量,链式中介效应占总的间接效应的26.14%。结论 差错管理氛围可直接影响护士的患者安全胜任力,并通过心理安全感及主动性行为的链式中介作用间接影响患者安全胜任力。管理者应营造积极的差错管理氛围,在患者安全管理中给予护士更多心理安全感,激发主动性行为,不断提升护士的患者安全胜任力水平。     

Inadequate pre-operative evaluation and preparation: a review of 197 reports from the Australian incident monitoring study

The Australian Incident Monitoring Study database was examined for incidents involving inadequate pre-operative patient preparation and/or evaluation. Of 6271 reports, 727 had appropriate keywords, of which 197 (3.1%) were used for subsequent analysis. All surgical categories were represented. In 10% of reports the patient was not reviewed pre-operatively by an anaesthetist, whilst in 23% the anaesthetist involved in the operating theatre had not performed the pre-operative assessment. Death followed in seven cases, major morbidity in 23 cases, admission to a high-dependency unit or intensive care unit in 17 cases, and surgery was cancelled in nine cases. Poor airway assessment, communication problems and inadequate evaluation were the most common contributing factors. Respondents indicated that the incident was preventable in 57% of cases. Proposed corrective strategies include improved communication, quality assurance activities, development of protocols and additional training. A structured assessment of the airway, along with improvements in information exchange, patient assessment, and use of clearly defined patient management plans and pathways would prevent most of the incidents reported.     

Major incident triage: Derivation and comparative analysis of the Modified Physiological Triage Tool (MPTT)

BackgroundTriage is a key principle in the effective management at a major incident. There are at least three different triage systems in use worldwide and previous attempts to validate them, have revealed limited sensitivity. Within a civilian adult population, there has been no work to develop an improved system.MethodsA retrospective database review of the UK Joint Theatre Trauma Registry was performed for all adult patients (>18 years) presenting to a deployed Military Treatment Facility between 2006 and 2013. Patients were defined as Priority One if they had received one or more life-saving interventions from a previously defined list.Using first recorded hospital physiological data (HR/RR/GCS), binary logistic regression models were used to derive optimum physiological ranges to predict need for life-saving intervention. This allowed for the derivation of the Modified Physiological Triage Tool–MPTT (GCS ≥ 14, HR ≥ 100, 12 < RR ≥ 22). A comparison of the MPTT and existing triage tools was then performed using sensitivities and specificities with 95% confidence intervals. Differences in performance were assessed for statistical significance using a McNemar test with Bonferroni correction.ResultsOf 6095 patients, 3654 (60.0%) had complete data and were included in the study, with 1738 (47.6%) identified as priority one. Existing triage tools had a maximum sensitivity of 50.9% (Modified Military Sieve) and specificity of 98.4% (Careflight). The MPTT (sensitivity 69.9%, 95% CI 0.677-0.720, specificity 65.3%, 95% CI 0.632-0.675) showed an absolute increase in sensitivity over existing tools ranging from 19.0% (Modified Military Sieve) to 45.1% (Triage Sieve). There was a statistically significant difference between the performance (p < 0.001) between the MPTT and the Modified Military Sieve.Discussion & conclusionThe performance characteristics of the MPTT exceed existing major incident triage systems, whilst maintaining an appropriate rate of over-triage and minimising under-triage within the context of predicting the need for a life-saving intervention in a military setting. Further work is required to both prospectively validate this system and to identify its performance within a civilian environment, prior to recommending its use in the major incident setting.     

In-hospital mortality of ruptured abdominal aortic aneurysm

Background: New Zealand, like Australia, has a widely dispersed population in towns at long distances from the main centres. We set out to estimate the in‐hospital mortality rate for ruptured abdominal aortic aneurysms in New Zealand and identify factors associated with mortality. Methods: Data were gathered prospectively as part of the Vascular Society of New Zealand’s continuous audit programme of all member surgeons. Data collection was validated by random record audit. In‐hospital mortality of ruptured abdominal aortic aneurysms, defined as death during hospital admission irrespective of cause, was determined for the period 1993–2005. Along with other performance indicators, differences in outcomes were assessed to take into account the trend over the time period, hospital size and number of non‐operative admissions. Results: Of the 740 patients admitted with a mean age of 73.9 ± 8.5 years, 78% were men and 17.8% were declined an operation. The in‐hospital mortality was 48.3% and the operative mortality was 37.8%. With univariate analysis increasing patient age, American Society of Anesthesiology score, hospital size and female sex were predictors of in‐hospital mortality. Only age and American Society of Anesthesiology score were independent predictors of operative mortality. Women were less likely to have surgery. Conclusion: Over the past 13 years in‐hospital mortality of ruptured abdominal aortic aneurysms in New Zealand remained unchanged. In provincial hospitals the operative outcomes were satisfactory, but the reported number not offered surgery was higher.     

Results from the Australasian Vascular Surgical Audit: the inaugural year

The Australian and New Zealand Society for Vascular Surgery has incorporated a constitutional change to administer a self-funded compulsory vascular surgery audit since January 2010. This is a bi-national quality assurance activity that captures all procedures performed in both countries. Data is collected at two points in the clinical admission; at operation and at discharge and data entry is via the Internet. Security is stringent and confidentiality is guaranteed by Commonwealth privilege. Data privacy is maximized by encryption. The application is flexible and administered by a dedicated administrator with a help-desk facility. Reports are available to provide real-time feedback of user performance compared with the peer group data in key categories of arterial surgery. A structured hierarchy for data management has been established to assess four main categories of performance: mortality after aortic surgery, stroke and death after carotid surgery, patency and limb salvage after infrainguinal bypass and patency after arteriovenous access for haemodialysis. Data is analysed using risk-adjustment techniques and an algorithm for management of underperformance has been followed. Data validation has been performed. The outcomes in all categories have been of a high standard and correction of erroneous data in a single statistical outlier has negated underperformance. The audit has captured only 65% of the estimated procedures in Australia in the first year, but data quality is good. The feasibility of a complete compulsory bi-national audit has now been established and will be the benchmark for other craft groups in the current environment of accountability.