ACTASM ANNUAL REPORT 2012 - RACS | Royal … · ACTASM ANNUAL REPORT 2012 ... 6. PROFILE OF...

Telephone: +61 2 6285 4558

Facsimile: +61 2 6285 3366

Email: [email protected]

Address: 3/13 Napier Close Deakin ACT 2600 Australia

Web: www.surgeons.org/actasm

ACTASM ANNUAL REPORT 2012ACT Audit of Surgical Mortality

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Contact

Royal Australasian College of Surgeons

Australian Capital Territory Audit of Surgical Mortality (ACTASM)

3/13 Napier Close

Deakin ACT 2600

Australia

Telephone: +61 2 6285 4558

Facsimile: +61 2 6285 3366


Website: www.surgeons.org/actasm

The information contained in this annual report has been prepared under the auspices

of the Royal Australasian College of Surgeons, Australian Capital Territory Audit of

Surgical Mortality Management Committee, which is a declared quality assurance

committee under the Health Act 1997.

The information contained in this annual report has been prepared by the Royal

Australasian College of Surgeons, Australian Capital Territory Audit of Surgical Mortality

Management Committee. The Australian and New Zealand Audit of Surgical Mortality,

including the Australian Capital Territory Audit of Surgical Mortality, has protection

under the Commonwealth Qualified Privilege Scheme under Part VC of the Health

Insurance Act 1973 (Gazetted 23 August 2011).

ACTASM 2011 Annual Report designed and printed by Entegy

(www.entegy.com.au); Brisbane, Australia.

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Contents

Tables 5

Figures 5

Chairman’s reporT 6

shorTened Forms 7

exeCuTive summary 8

1. INTRODUCTION 12

1.1 Background 12

1.2 Project governance and confidentiality 12

1.3 The audit process 13

1.3.1 Notification of deaths 13

1.3.2 Methods 13

1.3.3 Providing feedback 14

1.3.4 Audit inclusion and exclusion criteria 14

1.4 Reporting conventions 14

1.4.1 Terminology 14

1.4.2 Assessor opinion 15

1.4.3 Focus of reporting 15

1.5 Data 15

1.5.1 Data Entry 15

1.5.2 Storage of Data 15

1.5.3 Data Validity 16

1.5.4 Data Analysis 16

1.5.5 Denominator 16

2. AUDIT PARTICIPATION 17

2.1 Audit numbers 17

2.2 Surgeon participation 17

2.2.1 Surgeon Participation 17

2.2.2 Assessor participation 18

2.3 Surgeon participation by specialty 18

2.4 Surgeon completion of surgical case forms 18

2.5 Hospital participation 19

2.5.1 Participating hospitals 19

2.5.2 Time in hospital before death 19

3. PATIENT PROFILE 20

3.1 Age and gender 20

3.2 Acuity of audited cases 20

3.3 Clinical Risk Profiles 20

3.3.1 ASA Rating 20

3.3.2 Patients with comorbidities 21

3.3.3 Patients with a malignancy 21

3.4 Surgeon perception of risk status 22

4. RISK MANAGEMENT STRATEGIES 23

4.1 Prophylaxis for Venous Thromboembolism (VTE) 23

4.2 Fluid management 23

4.3 Provision of critical care support to patients 24

4.4 Antibiotic regime 24

5. CAUSE OF DEATH 25

5.1 Frequency of causes of death reported in audit period 25

5.2 Establishing cause of death 25

6. PROFILE OF OPERATIVE INTERVENTION 26

6.1 Operative intervention 26

6.2 Timing of surgical episodes 26

6.3 Seniority of surgeon operating 26

6.4 Postoperative complications 27

6.5 Anaesthetic problems 27

6.6 Transfers between hospitals in the ACT and NSW 27

7. PEER REVIEW OUTCOMES 29

7.1 Surgeon retrospective review 29

7.2 Second-line assessments 29

7.3 Clinical management issues 29

7.3.1 Perceived impact of clinical management issues 30

7.4 Improvements in care 32

8. CONCLUSIONS 33

9. ACKNOWLEDGMENTS 34

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Tables

Table 1: Comparison data: ACTASM 2012 and

ANZASM 2012 10

Table 2: ASA grade definitions 21

Table 3: Overview of post-mortems performed

in the ACT 25

Table 4: Perceived impact of clinical issues

groups 31

Figures

Figure 1: Governance structure, Royal Australasian

College of Surgeons, ANZASM and

ACTASM 12

Figure 2: Regional audit governance structure,

ACTASM 13

Figure 3: ACTASM methodology 14

Figure 4: Audit status 17

Figure 5: Participating public and private

hospitals, treating surgeons and

assessors in the ACT 18

Figure 6: Surgeon agreement to participate by

speciality 18

Figure 7: Number of surgical case forms

completed by each specialty 18

Figure 8: Classification of surgeon completing

surgical case form 19

Figure 9: Time in hospital before death 19

Figure 10: Gender distribution by age

bracket 20

Figure 11: Patient deaths by specialty 20

Figure 12: Distribution of ASA grades of audited

cases 21

Figure 13: Frequency of comorbidities 21

Figure 14: Percentage of patients with

malignancy 22

Figure 15: Risk of death as perceived by treating

surgeons 22

Figure 16: Type of VTE prophylaxis used 23

Figure 17: Issues in fluid balance 23

Figure18: Appropriateness of the antibiotic

regime 24

Figure 19: Most common causes of death 25

Figure 20: Timing of emergency surgical

episodes 26

Figure 21: Seniority of operating surgeon by

operation number 26

Figure 22: Frequency of postoperative

complications 27

Figure 23: Type of issues associated with patient

transfers 28

Figure 24: Frequency and spectrum of clinical

management issues recorded per

patient as recorded by assessors 30

Figure 25: Assessors perception of areas of

clinical management that could be

improved 32

Figure 26: Surgeons perception of areas of

clinical management that could be

improved 32

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Chairman’s reportThis is the second annual report for the Australian Capital Territory Audit of Surgical Mortality (ACTASM), covering data from 1 January 2012 to 31 December 2012. We are pleased with the progress made to date, with the audit covering all the public and private hospital sites in the ACT, and surgeon participation at 99%. I would like to personally thank all surgeons for helping us to achieve this high level of participation.

We are pleased to welcome RANZCOG (Royal Australian and New Zealand College of Obstetricians and Gynaecologists) Fellows to the audit process. This is the first year they have participated in the audit and participation rates are steadily increasing.

The Australian and New Zealand College of Anaesthetists (ANZCA) have also indicated interest in joining ACTASM. A representative of ANZCA now participates in the ACTASM Management Committee, and an application for Commonwealth Qualified Privilege has been lodged with results pending.

The Royal Australasian College of Surgeons (RACS) considers that participation in clinical audit is an essential facet of continuing professional development (CPD). As such, the College Council has mandated participation in one of the state/territory audits of surgical mortality as a component of recertification. The excellent participation rates within the ACT reflect this view, and I would encourage those clinicians who do not already act as an assessor to consider this role.

Undertaking an assessment is an enriching experience. The anonymity provided by the process offers an opportunity for open and honest clinical opinion. The second-line assessment, while time consuming, is both rewarding and educational. Surgeons who have done assessments are usually thorough in completing surgical case forms as they understand what detail is needed to offer a sound picture of the surgical care provided. We encourage all surgeons to review the case notes, complete all data fields and give your assessment of the case when completing the surgical case form.

ACTASM is part of a national network of similar audits, coordinated through the College by the Australian and New Zealand Audit of Surgical Mortality (ANZASM). As such, it contributes a territory-wide overview of surgical care from within the ACT to the national dataset. Both ACTASM and ANZASM rely on the quality and completeness of the data provided on the audit forms. The current audit forms have been revised and the increasing use of Fellows Interface, the college web-based platform, has certainly streamlined the processes of data submission and assessment. I encourage my colleagues to consider using this system if they have not yet done so. I am hopeful that, eventually, surgeons may be able to fill out the surgical case forms as soon as the death occurs, further streamlining the process and enabling the surgeon to complete the form while the case is still fresh in their mind.

ANZASM made a major contribution to the plenary session on safety and quality at the 2013 Annual Scientific Congress. Some publications are already in press and others are in preparation. ACT surgical trainees looking to gain experience in research and participate in quality improvement should be encouraged to approach ACTASM to access this valuable research data source.

The ACTASM Management Committee continues to provide good advice and constructive ideas on how to monitor, analyse and report trends associated with potentially preventable surgical mortalities. Two issues have been raised about the process. The first issue is that the audit does not review morbidities. At present, it is not within the scope of the audit to include morbidities, either at territory or national level. Inclusion of morbidity would require a much larger scale audit. This issue was forwarded to ANZASM for their consideration, and although it is being reviewed, the matter is still being considered by all the ASMs. The second issue is that of verifying the data in surgical case forms. It may be prudent to consider auditing a certain percentage of surgical case forms in the future to ensure that the data entry is accurate.

I hope that this report will be of interest to all practising surgeons and, as always, I welcome feedback about the process. I would like to thank the surgical community for participating, particularly the first- and second-line assessors and the ACTASM Management Committee for their contribution at every level of the process.

I would also like to extend my thanks to the College, which supports the process, and to the Project Manager, Ms Veronica Walker for her expertise and direction in driving the project forward. I would also like to acknowledge the commitment of the ACT Health for their support, advice and financial assistance, as well as the cooperation of the quality and health information management departments in the participating

hospitals.

Dr John Tharion

Clinical Director

ACTASM

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shortened Forms

ACT Australian Capital Territory

ACTASM ACT Audit of Surgical Mortality

ANZASM Australian and New Zealand Audit of Surgical Mortality

ANZCA Australian and New Zealand College of Anaesthetists

ASA American Society of Anaesthesiologists

CHASM Collaborating Hospitals Audit of Surgical Mortality

CPD Continuing Professional Development

DVT Deep Vein Thrombosis

HDU High Dependency Unit

ICU Intensive Care Unit

NSW New South Wales

RAAS Research, Audit and Academic Surgery

RANZCOG Royal Australian and New Zealand College of Obstetricians and Gynaecologists

SCF Surgical Case Form

SET Surgical Education and Training

SLA Second-Line Assessment

VTE Venous Thromboembolism

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executive summary

background

The ACT Audit of Surgical Mortality (ACTASM) is an audit process that provides

an independent, external peer review of all surgically-related deaths within the

ACT. It is systematic, objective and confidential, and its purpose is to inform and

improve surgical practice, with the ultimate goal of improving the quality of

patient care.

ACTASM is an initiative of the Royal Australasian College of Surgeons. It is

modelled on, and contributes data to, the bi-national Australian and New

Zealand Audit of Surgical Mortality (ANZASM). The ACT Health provides funding

and support in order to facilitate the audit process within all public and private

locations in the ACT. Similar mortality audits have been established in South

Australia, Queensland, Victoria, Tasmania and the Northern Territory. New

South Wales (NSW) provides comparable data to ANZASM but is independently

managed by the Clinical Excellence Commission of NSW.

objective

The objective of the audit is a ‘peer-review of all deaths associated with surgical

care’. This includes patients that were:

• under the care of a surgeon (surgical admission), whether or not an

operation was performed, or

• under the care of a physician (medical admission), and subsequently

underwent a surgical procedure.

The audit process is designed to highlight system and process errors and trends

in deficiencies of care. It is intended as an educational rather than as a punitive

exercise.

surgeon participation

• Surgeon participation in ACTASM stands at 99% (71/72) of consultant

surgeons in the ACT.

• This is the first year to include Fellows from the Royal Australian and New

Zealand College of Obstetricians and Gynaecologists (RANZCOG). Currently

38% (8/21) participate in ACTASM, with numbers increasing steadily.

• 75% (59/79) of participating consultants are first- and/or second-line

assessors in the ACTASM process. This number includes participating

RANZCOG Fellows.

hospital participation

• All private and public hospitals within the territory participate in ACTASM.

• The majority (97%) of completed cases were public patients.

audit numbers

• 112 deaths were reported to ACTASM.

• 63 cases had completed the full audit process and were analysed in this

report.

• 33 cases had not completed the full audit (peer-review) process and were

still under review by the end of the reporting period. Data from these cases

will be captured in next year’s report.

• 16 cases were excluded from the audit (admitted for terminal care,

inappropriately attributed to surgery).

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episode of care

• The median length of stay in hospital was five days (range <1 day – 58 days).

• 33% (21/63) of patients were transferred during their period of care, either

between ACT hospitals or from NSW.

• 78% patients underwent at least one surgical procedure and 11% required

more than one operation.

• The most frequent causes of death were cardiac and respiratory failure,

bowel ischaemia or obstruction, neurological and sepsis.

Risk profile of audited cases

• 51% of cases were male, with a median age of 71.

• 49% were female, with a median age of 82.

• 90% of audited deaths occurred in patients admitted as emergencies with

acute life-threatening conditions.

• 81% of cases had at least one pre-existing significant medical condition

(comorbidity).

• 63% of patients had an American Society of Anesthesiologists (ASA) grade

of 4 or above, indicating they had a condition that was a “constant threat to

life” (See section 3.3.1).

risk management

• 85% (53/62) of cases were assessed as having had appropriate venous

thromboembolism (VTE) prophylaxis.

• 57% (36/62) of patients received care in a critical care unit. In the 42% of

cases where the patient did not go to ICU, reviewers identified that the

patient may have benefited from it in 4% (1) of cases.

• Fluid balance in the surgical patient is an ongoing challenge and 3% (2) of

cases were assessed as having had poor management of fluid balance. In

20% (12/61) of cases the fluid balance status was unknown.

peer review outcomes

• 9% (6/69) of eligible cases were referred for second-line assessment (SLA)

or case note review.

• 95% (60/63) of cases identified either no issues or minor issues in clinical

management.

• 5% (3) of cases identified an area of concern or an adverse event. Further

detail is provided in section 7.3.

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Comparison data: aCTasm 2012 and anZasm 2012

Table 1: Comparison data: ACTASM 2012 and ANZASM 2012

Area for comparison

ACTASM (Oct 2011-Dec 2011)

%

ACTASM 2012

%

ANZASM 2012

%

Surgeon Participation 99% 99% 94%

Hospital Participation: Public 100% 100% 99%

Private 100% 100% 73%

Completed cases 14 63 2,870

Issues related to inter-hospital transfers

0 24% 32%

Male and Female ratio 36% : 64% 51% : 49% 54% : 46%

Emergency Admissions 93% 90% 86%

Admitted with one or more comorbidities

79% 81% 89%

ASA >4 63% 63% 58%

VTE prophylaxis use assessed as appropriate

71% 85% 92%

Issues in fluid balance 0 3% 9%

No issues or minor issues reported

86% 95% 87%

Areas of concern or adverse events

14% 5% 13%

Note: the reporting period for the ACTASM Annual Report has changed this year to bring it in line with the national reporting period. The table above is a comparison summary of:

1. ACTASM data for the unreported period: 1 October 2011 to 31 December 2011,

2. ACTASM data: 1 January 2012 to 31 December 2012,

3. ANZASM data: 1 January 2012 to 31 December 2012

performance review

Recommendations were included in the 2011 ACTASM Annual Report. The

following are achievements in relation to these recommendations:

• An audit was undertaken of cases which went to second-line review to

determine the accuracy of the information provided on the surgical case

form against the medical notes. Results:

> No inaccurate information was found in either of the surgical case

forms reviewed.

> The narrative at question nine In the surgical case form was very

brief in both cases. A more complete account of the episode of care

may have avoided the need for a second-line review.

> Recommendation: the project manager and clinical director to

review the surgical case form for completeness prior to providing

feedback to a surgeon following a second-line review. If it is

noted that more information could have minimised the need for

a second-line review, this feedback can be provided with other

recommendations to improve completion in future cases.

• All second-line assessments were sent interstate to ensure confidentiality.

• RANZCOG members are now participating in the audit.

• ANZCA participation is moving forward, with a representative from

ANZCA currently sitting on the ACTASM management committee. An

application to extend the Commonwealth Qualified Privilege to include

the anaesthetic specialty has been lodged with results pending.

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recommendations from 2012

• Increase surgeon’s participation as assessors to 80% by the end

of 2013.

• Increase participation by RANZCOG Fellows to 80% by the end

of 2013.

• Decrease response times for surgical case forms for slow

responders (Target <45 days).At present 80% of surgical case

forms were returned by the census date. The plan is to aim for

a return rate of 95%.

• Identify potential improvements to the Fellows Interface to

make it more user friendly and thus increase its utilisation.

• Continue to contribute data to ANZASM, and to National Case

Note Review Booklets. Develop ACT Clinical Case Note Review

Booklet in collaboration with a larger state.

• Facilitate future participation of anaesthetists in ACTASM.

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1. inTroduCTion

KEY POINTS

• ACTASM is an independent peer-reviewed

audit of deaths that occur while patients

are under surgical care. The process

involves self-reporting by surgeons and

peer review by first- and second-line

assessors.

• This report covers the census period

1 January 2012 to 31 December 2012.

This report is an analysis of the 63 cases

that completed the full audit process

during the period.

• The reporting period has changed to

bring ACTASM in line with National

ANZASM reporting timelines.

• This is the first year to include fellows

from the Royal Australian and New

Zealand College of Obstetricians and

Gynaecologists (RANZCOG).

1.1 background

The ACT Audit of Surgical Mortality (ACTASM) is

an audit process that provides an independent,

external peer review of all surgically-related

deaths within the ACT. It is systematic, objective

and confidential, and its purpose is to inform and

improve surgical practice, with the ultimate goal of

improving the quality of care for patients.

ACTASM is an initiative of the Royal Australasian

College of Surgeons. It is modelled on, and

contributes data to, the bi-national Australian and

New Zealand Audit of Surgical Mortality (ANZASM).

ACT Health provides funding and support in order

to facilitate the audit process within all public

and private locations in the ACT. The ACTASM

Management Committee meets quarterly and

oversees the project. This constitutes an invaluable

foundation to the running and success of the audit

program.

ACTASM commenced collecting data in October

2010. The 2011 Annual Report reported on the

period October 2010 - September 2011. In order

to bring the reporting period in line with ANZASM,

the 2012 Annual Report includes data collected

from 1 January 2012 to 31 December 2012, with

the data not previously reported on from October

to December 2011 included in a comparison table

in the executive summary.

Only cases which have completed the audit process

and are closed are included for analysis in the

report. Due to the nature of the audit process,

some cases will not be completed by the census

date. These cases will be included in the 2013

report.

1.2 project governance and confidentiality

The governance structure of ANZASM is illustrated

in Figure 1. The regional ACTASM governance

structure is illustrated in Figure 2.

The Royal Australasian College of Surgeons

Australian Capital Territory Audit of Surgical

Mortality Management Committee has been

gazetted as a Quality Assurance Committee under

the Commonwealth Qualified Privilege Scheme

under Part VC of the Health Insurance Act 1973

(gazetted 23 August 2011).

Participation in a regional audit is now a mandatory

component of attaining Continuing Professional

Development (CPD) recertification. Participating

surgeons and assessors gain points in Category

1 of the CPD program: ‘Clinical Governance and

Evaluation of Patient Care’.

Figure 1: Governance structure, Royal Australasian College of Surgeons, ANZASM and ACTASM

ACT Health Minister College Council

ACTASM Management

Committee

ACT Participating Hospitals

ACT Health

ACT Consultant Surgeons

College Professional Development and Standards Board

Research, Audit and Academic Surgery Board

ANZASM Steering Committee

ACTASM Project Staff

Note: ANZASM: Australian and New Zealand Audit of Surgical Mortality; ACT: Australian Capital Territory; ACTASM: Australian Capital Territory Audit of Surgical Mortality.

ACTASM Project Manager

ACT Hospitals

ACT Minister for Health

And

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Figure 2: Regional audit governance structure, ACTASM

ACT Health Minister

ACT Health

ACTASM Management

Committee


ACT Consultant Surgeons ACT Hospitals

ANZASM (RAAS Division,

Adelaide)

Note: ACT: Australian Capital Territory; ACTASM: Australian Capital Territory Audit of Surgical Mortality; ANZASM: Australian and New Zealand Audit of Surgical Mortality; RAAS Division: Research, Audit and Academic Surgery Division.

1.3 The audit process

1.3.1 Notificationofdeaths

ACTASM audits public and private hospital deaths

that occurred during an episode of surgical care,

whether or not the patient underwent a surgical

procedure. This can include cases where a surgeon

was involved in the management of a patient

admitted by another team, or cases transferred to

the surgeon’s care during that admission.

The medical records departments of the

participating hospitals, both public and private,

notify ACTASM of all surgically-related deaths.

Each participating hospital is aware of the inclusion

criteria of ACTASM (see 1.3.4) and reports those

deaths monthly, or as required.

1.3.2 Methods

ACTASM methodology is described below, with an

overview included in Figure 3 below.

ACTASM receives notification of a surgically-

related death (via password-protected email) from

participating hospitals. This information is entered

into a secure database and a surgical case form

(SCF) is then sent to the consultant surgeon for

completion, either via Fellows Interface or a paper

version. The SCF is a nine-page structured form,

in which the surgeon is asked to document the

details of the case, including whether there were

any clinical incidents during the care of the patient.

The consultant surgeon then returns the SCF to

the ACTASM project office.

The SCF is then coded and de-identified and sent

to a different surgeon for peer review, or first-

line assessment (FLA). The first-line assessor is

a consultant surgeon of the same specialty. The

first-line assessor determines whether the case

should undergo further assessment (second-line

assessment-SLA), which involves reviewing de-

identified medical records of the case. The first-line

assessor may also close the case at this stage. The

first-line assessor may find no clinical incidents

or may find clinical incidents which do not need

further assessment.

A primary objective of the peer-review process

is ascertaining if death was a direct result of the

disease process alone or if aspects of management

of the patient might have contributed to that

outcome. If there is a perception that the clinical

management may have contributed to death,

ANZASM specifies that these are reported against

the following criteria:

• area for consideration—where the clinician

believes an area of care could have been

improved or different, but recognises that

there may be debate about this

• area of concern—where the clinician believes

that an area of care should have been better

• adverse event—where an unintended ‘injury’

is caused by medical management, rather than

by the disease process, which is sufficiently

serious to:

> lead to prolonged hospitalisation

> lead to temporary or permanent

impairment or disability of the patient at

the time of discharge, or

> contribute to or cause death.

Cases undergo a second-line assessment if:

• an area of concern has been identified or an

adverse event is thought to have occurred

during the clinical care of the patient that warrants further investigation

• there is insufficient information on the SCF

for the assessor to reach a conclusion

• a report could usefully draw attention to

‘lessons to be learned’, either for clinicians

involved in the case, or as part of the

collated case note review booklet for wider

distribution within the surgical community.

some cases will not be completed by the census

date. These cases will be included in the 2013

report.

1.2 project governance and confidentiality

The governance structure of ANZASM is illustrated

in Figure 1. The regional ACTASM governance

structure is illustrated in Figure 2.

The Royal Australasian College of Surgeons

Australian Capital Territory Audit of Surgical

Mortality Management Committee has been

gazetted as a Quality Assurance Committee under

the Commonwealth Qualified Privilege Scheme

under Part VC of the Health Insurance Act 1973

(gazetted 23 August 2011).

Participation in a regional audit is now a mandatory

component of attaining Continuing Professional

Development (CPD) recertification. Participating

surgeons and assessors gain points in Category

1 of the CPD program: ‘Clinical Governance and

Evaluation of Patient Care’.

Figure 1: Governance structure, Royal Australasian College of Surgeons, ANZASM and ACTASM

ACT Health Minister College Council

ACTASM Management

Committee

ACT Participating Hospitals

ACT Health

ACT Consultant Surgeons

College Professional Development and Standards Board

Research, Audit and Academic Surgery Board

ANZASM Steering Committee

ACTASM Project Staff

Note: ANZASM: Australian and New Zealand Audit of Surgical Mortality; ACT: Australian Capital Territory; ACTASM: Australian Capital Territory Audit of Surgical Mortality.


ACT Hospitals

ACT Minister for Health

And

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The second-line assessor is a senior consultant

surgeon of the same specialty, but not from the

same hospital as the original surgeon. The ACT

surgical community is very small and it is difficult

to ensure that a case is not identifiable at this

level. Therefore, all ACT second-line cases are sent

interstate. In order that ACT assessors receive the

educational opportunity to review second-line

cases, the other state sends one of their second-

line cases to the ACT for review.

1.3.3 Providingfeedback

ACTASM provides feedback in the following ways:

• Surgeons receive written feedback from first-

and second-line assessors (de-identified) on

their ACTASM cases.

• Hospitals participating in ACTASM may

request reports on aggregated de-identified

data relating specifically to their hospitals

and comparing them to the averages of other

hospitals.

• Annual reports and case note review booklets

are available to the surgical community on

the ACTASM website at www.surgeons.org/

actasm.

The aggregated feedback and related clinical

events in annual reports and case note review

booklets are not linked to individual patients,

surgeons or hospitals. The process is managed by

the ACTASM Project Manager, following ANZASM

guidelines, and is coordinated through a secure

database.

1.3.4 Auditinclusionandexclusioncriteria

ACTASM includes all deaths that occurred in a

participating hospital when:

• the patient was under the care of a surgeon

(surgical admission), whether or not an

operation was performed, or

• the patient was under the care of a physician

(medical admission), and subsequently

underwent a surgical procedure.

ACTASM excludes deaths when:

• the patient is admitted for terminal care, or

• the case does not fulfil either of the above

criteria.

Figure 3: ACTASM methodology

ACTASM receives notification of death

Surgical case form sent to surgeon for completion

Completed surgical case form returned to ACTASM and de-identified

First-line assessment

Second-line assessment

Feedback to surgeon

Is second-line assessment appeal required?

Yes

Yes

No

No

Case closed

Case closed


required?

Note: ACTASM: Australian Capital Territory Audit of Surgical Mortality.

1.4 reporting conventions

1.4.1 Terminology

Surgeons and assessors are asked to review the

case and to determine whether there were any

clinical incidents where care could have been

improved. These are then classified as an area of

consideration, an area of concern or an adverse

event.

• An area of consideration occurs where the

clinician believes an area of care could have

been improved or different, but recognises

that this may be an area of debate

• An area of concern is where the clinician

believes that areas of care should have been

better

NoYes

Case closed

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• An adverse event is an unintended injury

caused by medical management, rather

than by disease process, which is sufficiently

serious to lead to prolonged hospitalisation,

to temporary or permanent impairment, or

which contributes to or causes death.

The clinician is then asked to give their opinion as

to:

• Whether the incident was preventable, under

the categories:

> definitely

> probably

> probably not

> definitely not.

For this report, both the categories of ‘definitely’

and ‘probably’ are referred to as being

preventable.

• Who the incident was associated with,

categorising this information as:

> audited surgical team

> another clinical team

> hospital

> other.

• The impact of the incident on outcome, based

on whether the event:

> made no difference to outcome

> may have contributed to death

> caused the death of a patient who

would otherwise have been expected to

survive.

1.4.2 Assessor opinion

The areas for consideration, areas of concern

and adverse events contained in this report were

events ascribed to the case by the highest level

of assessment, either the first-line assessor or the

second-line assessor if the case progressed that

far. For ease of reporting, these are referred to as

‘assessors’.

The categorisation of the severity of the event, the

effect on outcome, and the team or location the

event was associated with, are the opinions of the

assessors.

1.4.3 Focusofreporting

ACTASM reports focus primarily on areas of

concern and adverse events (see 1.4.1). Areas

for consideration are excluded from this analysis

because they have minimal impact on the outcome

and are simply an indication that there were

different clinical opinions. However, areas for

consideration are included in the data collection

process to facilitate reporting of ‘less serious’

events, which is important for improving overall

patient care. It is also noteworthy that in some

areas of reporting all criteria are not mutually

exclusive and, therefore, percentages will not add

up to 100%. Some cases have no clinical incidents

reported, while others were associated with

several. In this situation, where analysis of clinical

incidents was reported by case, the most serious

incident was ascribed to the case.

1.4.4 Completenessofinformation

Numbers in parentheses in the text (n) represent

the number of cases analysed. In some surgical

case forms, not all data fields were completed by

clinicians; therefore, the total number of cases

used in different sections of the analysis varies.

Clinicians are encouraged to complete all data

fields in order to provide a complete report.

The use of Fellows Interface, the College online

platform, improves compliance by prompting the

clinician if fields are left incomplete.

1.5 data

This report covers deaths notified to ACTASM from

1 January 2012 to 31 December 2012. The census

date for this report was 4 May 2013.

ACTASM analysed areas of concern or adverse

events ascribed to each case by assessors.

Due to the audit process and the timing of

return of forms, some cases reported to ACTASM

during 2012 will, at the time of analysis, still be

undergoing review. These cases will be included in

the 2013 annual report.

1.5.1 DataEntry

Data is entered in two ways:

1. The data may be entered directly onto the

database by the clinician via Fellows Interface.

It is then checked and coded by the project

manager.

2. A hardcopy may be completed and sent to the

project manager, who transcribes the data to

the database.

Use of the Fellows Interface will eliminate

potential transcription errors, and ensure

completeness of data by prompting the clinician if

fields are left incomplete.

1.5.2 StorageofData

Data is encrypted in the database with Secure

Sockets Layer certificates. This data is sent to and

stored in a central Structured Query Language

Figure 3: ACTASM methodology

ACTASM receives notification of death

Surgical case form sent to surgeon for completion

Completed surgical case form returned to ACTASM and de-identified

First-line assessment


Feedback to surgeon

Is second-line assessment appeal required?

Yes

Yes

No

No

Case closed

Case closed


required?

Note: ACTASM: Australian Capital Territory Audit of Surgical Mortality.

1.4 reporting conventions

1.4.1 Terminology

Surgeons and assessors are asked to review the

case and to determine whether there were any

clinical incidents where care could have been

improved. These are then classified as an area of

consideration, an area of concern or an adverse

event.

• An area of consideration occurs where the

clinician believes an area of care could have

been improved or different, but recognises

that this may be an area of debate

• An area of concern is where the clinician

believes that areas of care should have been

better

NoYes

Case closed

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server database, which includes a reporting engine.

All transactions are time stamped. All changes to

audit data are recorded in an archive table enabling

a complete audit trail to be created for each case.

1.5.3 DataValidity

When indicated, information is checked against

the original SCFs and assessment forms. Medical

records departments, surgeons, the Coroner’s

Office reports and the Chairman are all resources

used by ACTASM to maintain data integrity.

1.5.4 DataAnalysis

The Project Manager and Clinical Director

independently classify all qualitative information

into groups. These groupings are then compared

and any differences discussed until consensus is

reached.

1.5.5 Denominator

The denominator used is the total number of cases

for which there is data available. It will be indicated

by (n). This will vary between questions as:

• Some questions can have multiple responses

for the same case, for example, some cases

will have no clinical incidents reported while

others may be associated with several.

• Some questions on the audit forms contain

sub-questions, which may not require

completion for all cases.

• A clinician may miss a question, or may not

answer it if they are unsure.

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2. audiT parTiCipaTion

KEY POINTS

• There were 112 surgically-related deaths

reported to ACTASM for the census

period 1 January 2012 to 31 December

2012 and 56% (63/112) of cases had

completed the full audit process.

• 100% of public and private hospitals

participate in ACTASM.

• 99% (71/72) of ACT consultant surgeons

are participating in ACTASM.

• 38% (8/21) of RANZCOG Fellows are

participating in ACTASM. This is the first

year of RANZCOG participation in the

audit and participation is growing steadily.

• 75% (59/79) of participating consultants

have agreed to be a first- and/or second-

line assessors in the audit and this number

continues to increase. This number

includes participating RANZCOG Fellows.

2.1 audit numbers

A total of 112 deaths were reported to ACTASM.

• Of the 112 cases, a total of 56% (63/112) of

cases had proceeded to and completed the

audit process. The clinical information from

these 63 deaths provides the patient profiles

described in this report and is the denominator

in all analyses pertaining to outcomes from the

audit, unless stated otherwise.

• A total of 29.5% (33) of cases had not

completed the full audit (peer-review)

process. This includes 20% (22) where forms

were not fully completed or returned by the

surgeon, 4% (5) of cases awaiting first-line

assessments and 5% (6) of cases sent for

second-line assessment.

• 14.5% (16) of cases were excluded from the

audit. Of the 16 cases which were excluded,

15 cases (13% of total) were identified as

terminal cases, where palliative measures

were instituted following initial patient

assessment. The remaining case (1% of total)

was excluded as the surgeon was identified as

not participating (i.e. locum).

• This completion rate is comparable to the

nationally reported rate of 55% (ANZASM

National Report 2012).

It should be noted that:

• The audit process relies not only on surgeons agreeing to participate, but also on their timely completion and return of surgical case and assessment forms.

• There will always be ACTASM forms pending. This reflects the continuous nature of the audit with surgeons interacting with ACTASM

on a regular basis.

Figure 4: Audit status

14.5%

29.5%

56%

Completed In progress* Excluded (Terminal care)

Note: N=112; * In progress cases are made up of surgical case forms and first- and second-line assessment forms that remain outstanding.

2.2 surgeon participation

2.2.1 SurgeonParticipation

During the period 1 January 2012 to 31 December 2012, 99% (71/72) of eligible surgeons from the Royal Australasian College of Surgeons participated in ACTASM. Nationally, the participation rate for surgeons is 94%, as at the end of 2012. Surgeons are considered to be participating when they submit an ‘Agreement to Participate’ form and they have no outstanding cases older than three months. Surgeons can opt to undertake the role of assessor using this form. An ‘Assessor Declaration’ form must also be completed before any cases are assessed.

In 2012, RANZCOG agreed to collaborate with RACS to collect gynaecologically-related mortality data within ACTASM. By the end of 2012, 38% (8/21) of eligible fellows from RANZCOG were participating and the number is steadily increasing.

The Australian and New Zealand College of Anaesthetists (ANZCA) have indicated interest

in joining ACTASM. A representative of ANZCA

now participates in the ACTASM Management

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Committee and an application for Commonwealth

Qualified Privilege has been lodged, with results

pending.

2.2.2 Assessor participation

A total of 75% (59/79) of participating consultants

have agreed to be a first- and/or second-line

assessors and this number continues to increase.

This number includes participating RANZCOG

Fellows.

Figure 5: Participating public and private hospitals, treating surgeons and assessors in the ACT

100%

80%

60%

40%

20%

0%

ACT Hosp

itals

Treatin

g FRACS

Surgeons

Treatin

g RANZCOG^

Surgeons

Assess

ors*

Perc

enta

ge P

arti

cip

atin

g

ACT: Australian Capital Territory.

* ACT assessors also review inter-state assessments.

^ RANZCOG—Royal Australian and New Zealand College of Obstetricians and Gynaecologists

2.3 surgeon participation by specialty

The specialty distribution of participating surgeons

is seen below in Figure 6. All specialties are

currently participating in ACTASM.

Figure 6: Surgeon agreement to participate by speciality

20

15

10

5

0

Speciality

Num

ber

of

Surg

eons

Orthopaedic Surg

ery

Urology

Cardioth

oracic Surgery

General Surg

ery

Neurosu

rgery

Vascular Surg

ery

Otolaryngology

Plastic Surg

ery

Paediatric Surg

ery

Note: N=71

Within the ACT, some specialties include a very

small cohort. In order to maximise the peer-review

process, assessments should be undertaken by a

surgeon who is of an equivalent area of expertise

and who has not been previously asked to provide

expert advice independently on the case (e.g.,

in a local or inter-jurisdictional clinical review

process). This is to maintain the objectiveness

and transparency of the review and protects the

identity of the treating surgeon. Therefore all

second-line and some first-line cases are assessed

interstate to ensure that both criteria are met and

the treating surgeon has the most benefit from the

peer-review component of this audit.

2.4 surgeon completion of surgical case forms

Of the 112 notifications of death reported from

the 1 January 2012 to 31 December 2012, 16 cases

were excluded due to terminal care. A total of 56%

(63/112) of cases completed the full audit cycle.

This is lower than the national rate of 80%. The

percentage of each specialty is shown in Figure 7

below. The median time taken to return a SCF was

55 days (n=91).

Figure 7: Number of surgical case forms completed by each specialty

50

40

30

20

10

0

Speciality

Num

ber

of

Surg

eons

Orthopaedic Surg

ery

Urology

Cardioth

oracic Surgery

General Surg

ery

Neurosu

rgery

Vascular Surg

ery

Otolaryngology

Obstetri

c & Gynaecology

SCF Returned

SCF Pending

Note: Number of notifications of death without excluded cases = 96.

The information collected through the SCF fields

contributes to a national dataset which presents

a clear picture of surgical care provided. In some

fields, the treating surgeon is asked for a clinical

opinion, which is crucial to the surgical picture.

These fields must be completed for the audit to

meet its core objective, namely for participants to

learn from each other. Clinical opinion strengthens

the meaning of, and gives credibility to, the

national dataset.

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The first-line assessor makes a fair determination

and provides constructive feedback based on the

SCF alone. This can cause some indecision if the

form has not been filled in completely and all the

information is not to hand.

In the audit form, the assessor is asked, ‘Was there

enough information to make a determination?’

The process directs that a case without sufficient

information should be referred for a second-

line assessment (case note review). Assessors

sometimes ask if further information could be

sought from the treating surgeon before referring

the case for a second-line review. This has been

undertaken in the ACT and has met with varying

degrees of success.

The consultant in charge of the case can delegate

the task of completing the surgical case form to

the Registrar or Fellow in charge of the case. This

provides an opportunity for reflection for the

registrar and can guide discussion of areas for

improvement when the consultant reviews the

surgical case form with the registrar. See Figure 8

for classification breakdown. No data is available

for who was completing the form for excluded

cases. The consultant retains the responsibility of

overseeing the detail of the form submitted.

Figure 8: Classification of surgeon completing surgical case form

12%

6%

84%

Consultant Service Registrar SET Trainee

Note: N=77 includes all completed surgical case forms except those cases excluded for terminal care (classification of surgeon completing SCF not indicated on excluded forms)

2.5 hospital participation

2.5.1 Participatinghospitals

All public and private hospitals within the ACT

currently participate in the audit by reporting

surgically-related deaths to ACTASM. Hospitals

in the ACT range from small private hospitals to

large public teaching hospitals. Each participating

hospital is aware of ACTASM’s inclusion criteria

(see 1.3.4) and reports those deaths through a

monthly report, or as required in smaller facilities.

In the period 1 January 2012 to 31 December

2012, all cases were notified by the two main

public hospitals. The other participating hospitals

have had no notifications during the audit period.

2.5.2 Timeinhospitalbeforedeath

The average length of stay of patients in hospital is

shown in Figure 9 below.

Figure 9: Time in hospital before death25%

20%

15%

10%

5%

0%

Length of Stay

Perc

enta

ge o

f ca

ses

6-8 days

9-11 days

<1-2 days

3-5 days

12-14 days

15-17 days

18-20 days

>20 days

Note: N=63.

Comment:

• The median length of stay in hospital was five days with a range of less than one day to 58 days. The mean length of stay was 10 days.

• 60% of patients died in the first week of admission and a further 16% in the second week (data not shown).

• The longest patient admission was 58 days, which was predominantly a medical admission

whilst awaiting fitness for surgery.

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3. paTienT proFile

KEY POINTS

• 90% of audited deaths occurred in

patients admitted as emergencies with

acute conditions.

• The median age for males was 71 years

and for females was 82 years.

• 81% of audited cases had one or more

significant comorbidities that were

reported to have contributed to the

death.

• 63% per cent of audited cases had

a recorded American Society of

Anaesthesiologists (ASA) score of 4 or

more.

• 97% were public patients.

3.1 age and gender

Sixty-three cases had completed the audit process,

and these cases were used for further analysis.

Figure 10 below details the distribution of the

sample by age group and subdivided by gender.

Figure 10: Gender distribution by age bracket

25

20

15

10

5

0

Age

Num

ber

of

Surg

eons Male

Female

0-20 21-40 41-60 61-80 81+

Note: N=63.

Comment:

• 51% (32) of cases were male and 49% (31)

were female.

• The median age of females in the sample

was 82 years versus 71 years for males: a

difference of 11 years.

• There were a higher proportion of males

under the age of 80 than females. Females

predominated in the 80+ age range.

3.2 acuity of audited cases

The ‘acuity’ status of audited cases indicated

whether patients were admitted electively

or as emergencies. There were 90% (57) of

audited deaths occurring in patients admitted as

emergencies for acute life-threatening conditions.

This is comparable to the national rate of 86%. In

78% (49) of patients had at least one operation

during their episode of care (see Section 6 for

further detail).

Figure 11: Patient deaths by specialty

60

50

40

30

20

10

0

Speciality

Cas

es (%

)

Orthopaedic Surg

ery

Cardioth

oracic Surgery

General Surg

ery

Neurosu

rgery

Vascular Surg

ery

Otolaryngology

Ophthalm

ology

Note: N=63.

Comment:

• 54% of deaths occurred within the general

surgery specialty, 24% within orthopaedic

surgery, 10% in neurosurgery, 6%

cardiothoracic, 3 % vascular surgery, and 2%

in each of ophthalmology and otolaryngology

Head and neck.

• The distribution between specialties was

appropriate to the case-mix of the individual

specialties.

3.3 Clinical Risk Profiles

This section reviews the risk profile of audited

cases. This includes the American Society of

Anaesthesiologists (ASA) status, reported

comorbidities and the treating surgeon’s

perception of risk of death. The clinical risk profile

indicates that the majority of deaths occurred in

patients with comorbidities presenting with acute

life-threatening conditions.

3.3.1 ASARating

The ASA grade is an internationally recognised

classification of perioperative risk. An ASA grade

is assigned to a preoperative patient by an

anaesthetist. In the surgical case form, the surgeon

has been asked to grade their patients using this

scale. Grade definitions can be seen in Table 2

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below. The distribution of grades within audited

cases is shown in Figure 12.

Table 2: ASA grade definitions

ASA Grade

Characteristics

1 A normal healthy patient

2 A patient with mild systemic disease

3A patient with severe systemic disease which limits activity, but is not incapacitating

4A patient with incapacitating systemic disease which a constant threat to life

5A morbid patient who is not expected to survive 24 hours, with or without an operation

6 A brain dead patient for organ donation

Figure 12: Distribution of ASA grades of audited cases

50

40

30

20

10

0

ASA 1&2 3 4 5&6

Perc

enta

ge o

f p

atie

nts

ASA Grade

Note: N=51. Grades were not available in 12 cases.

Comment:

• 63% (32/51) of cases had a recorded ASA

grade of 4 or more, as described by the

surgeon. The frequency of high ASA grades

indicates that most deaths occurred in

patients whose preoperative health was

assessed as high risk.

In the ANZASM 2010 report, ACT had a higher

percentage of cases rated ASA 1 and 2 in comparison

to other states. This was analysed by the project

manager and the results analysed by ACTASM

Management Committee. The ASA rating assigned

by the anaesthetist in cases that underwent surgery

was compared to the ASA rating given by the

surgeon in the Surgical Case Form. No significant

differences were found on comparison.

The 2012 ACT ASA ratings are in line with the

national figures from the 2012 ANZASM Report.

Across the regions the percentage of cases rated

ASA 1 & 2 varied from 8% to 20%. ACTASM will

continue to monitor this trend.

3.3.2 Patientswithcomorbidities

Surgeons were asked to identify the following

comorbidities in addition to the primary medical

(presenting) problem: cardiovascular, respiratory,

renal, hepatic, neurological, advanced malignancy,

diabetes, obesity and age (as shown in Figure

13). A patient may present with more than one

comorbidity.

Figure 13: Frequency of comorbidities

35%

30%

25%

20%

15%

10%

5%

0%

Comorbidity

Freq

uenc

y (%

)

Advanced malig

nancyRenal

Hepatic

Obesity

Diabetes

Neurological

Respira

tory

Advanced age

Other*

Cardiovascular

Note: N=51, number of comorbidities = 113. * Other comorbidities covered a wide range and included anaemia, dementia, and infection.

Comment:

• 81% (51/63) of audited cases were reported

to have one or more significant comorbidity

which was considered to have increased

the risk of death. This compares with 89%

nationally.

3.3.3 Patientswithamalignancy

Malignancy was present in 35% (22/63) of cases,

with metastatic disease present in 21% (13/63).

Surgeons considered that the malignancy

contributed to the patient’s death in 15 (24%)

cases (as shown in Figure 14).

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Figure 14: Percentage of patients with malignancy

40%

35%

30%

25%

20%

15%

10%

5%

0%

Present Metastatic Contributed to death

Patients with malignancy

Perc

enta

ge o

f p

atie

nts

wit

h m

alig

nanc

y

Note: N=62. Data not available in 2% (1) case.

3.4 surgeon perception of risk status

The treating surgeons were asked to record the

perceived risk of death of the patient at the time

of treatment and to rate the overall risk of death

(before any surgery) for each patient (as shown in

Figure 15).

Figure 15: Risk of death as perceived by treating surgeons

12%

8%

18%61%

Expected

Small Moderate Considerable

Note: n=49. This question is only asked where the patient underwent a surgical procedure

Comment:

• In 8% (4) of cases, the perceived risk was

considered small.

• In 73% (36) of cases, the perceived risk of

death was considerable or expected which

compares with 62% nationally.

• This was further evidence of the high-risk

profile suggested by the mean age, ASA score

and associated comorbidity.

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4. risK managemenT sTraTegies

KEY POINTS

• 85% (53/62) of cases, the VTE prophylaxis

provided was assessed as appropriate.

• Fluid balance in the surgical patient is an

ongoing challenge. In this series, 6% (4/63)

of cases were perceived to have had poor

management of fluid balance.

• In the majority of instances, those patients

expected to benefit from critical care

support did receive it. The review process

suggested that 4% (1) of patients who did

not receive treatment in critical care would

have benefitted from it.

4.1 prophylaxis for venous Thromboembolism (vTe)

The treating surgeon was asked to record if venous

thromboembolism (VTE) prophylaxis was given

and, if so, which form of prophylaxis was used (see

Figure16). If VTE prophylaxis was not given, the

surgeon recorded the reason it was withheld. The

assessors were asked to review whether these

decisions were appropriate.

VTE prophylaxis use was recorded in 83% (49/59)

of patients which compares with 78% nationally.

• Of the patients who did not have VTE

prophylaxis, surgeons indicated that:

> for 10% (6), it was an active decision to

withhold treatment due to the patient’s

condition

> for 12% (7), it was considered not

appropriate, and

> for 2% (1), it was not considered.

• Assessors viewed the use of VTE prophylaxis

as appropriate in 85% (53/62) of cases,

unknown in13% of cases (8/62) and not

appropriate in 2% (1/62).

There were 90 instances of use of VTE prophylaxis

in 49 cases. Figure 16 indicates the number of

patients who received VTE prophylaxis, according

to the method used.

Figure 16: Type of VTE prophylaxis used50

40

30

20

10

0

Num

ber

of

pro

phy

laxi

s gi

ven

Type of prophylaxis given

Sequential

compressi

on deviceOth

er*

Heparin (a

ny form

)

TED^ stockings

Wartf

arin

Aspirin

Note: N=90. Data not available in 4 cases. Other* agents recorded were Clexane, Clopidogrel and Heparin infusion. TED^: thromboembolic deterrent; VTE: venous thromboembolism.

4.2 Fluid management

This section and Figure 17 shows the

appropriateness of fluid balance in 63 patients.

Figure 17: Issues in fluid balance

60

50

40

30

20

10

0

Fluid balance Appropriatness

Cas

es (n

)

Assessor

Surgeon

Yes No Unknown

Note: Surgeons N= 63; Assessors n=61.

Comment:

• Surgeons reported fluid management issues in

6% (4/63) of cases. By comparison, assessors

reported fluid management issues in 3%

(2/61) of cases; however, assessors reported

feedback as ‘unknown’ in 20% (12/61) cases.

Nationally, assessors felt that 15% of cases

had issues with fluid balance and 8% were

unknown.

• The high rate of ‘unknown’ responses by the

assessors is a clear indicator that there was

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insufficient information on the surgical case

form to make a determination on this aspect

of care. Where fluid balance is not usually

an issue (e.g. neurosurgery) the treating

surgeon has not recorded it as it is not seen as

relevant. Fluid balance issues are more often

general surgical in nature.

4.3 provision of critical care support to patients

The treating surgeon was asked to record whether

or not a patient received critical care support in an

intensive care (ICU) or high dependency unit (HDU)

before or after surgery. The assessors reviewed

the appropriateness of the use of critical care

support. It was recognised that this is a subjective

assessment of needs and potential benefit.

Within the ACT, 58% (36/62) of the audit group

were admitted to the ICU and/or HDU for care

during their admission. In the 42% (26/62) of cases

where the patient did not go to critical care, the

assessor’s considered that 4% (1) would have

benefited from an admission to ICU and/or HDU.

In 81% of the cases admitted to the ICU/HDU,

surgeons were happy with the care delivered.

Where there was dissatisfaction, a number of

surgeons across different specialities felt strongly

about not being involved in the discussions, or

the decision to withdraw active treatments for

their patient and institute end-of-life care. This

lack of involvement in the change of care was

also reported as an area of consideration, as it

constituted a difference of clinical opinion. This

trend is similar across all regions.

The SCF will be revised in September 2013 to

identify the reasons why patients did not receive

critical care support. It is hoped that this will

encourage surgeons to fully complete the form

and thus ensure sufficient data for analysis in this

area of care.

4.4 antibiotic regime

Surgeons were asked if they considered the

antibiotic regime to be appropriate.

Figure18: Appropriateness of the antibiotic regime

9%

11%

79%

Yes No Not known

Note: N= 53. Data not available in 10 cases.

Comment:

• In 19% (12/63) of cases, the patient died with

a clinically significant infection. In 11% (7/63)

of cases, these infections were acquired

postoperatively, with only 2% (1/63) of cases

identified with a surgical site infection.

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5. Cause oF deaTh

KEY POINTS

• The most frequent causes of death

were cardiac and respiratory failure,

bowel ischaemia or obstruction,

neurological and sepsis.

5.1 Frequency of causes of death reported in audit period

Figure 19: Most common causes of death

16

14

12

10

8

6

4

2

0

Cause of death

Freq

uenc

y (n

)

Cardiac r

elated

Neurolo

gical

Sepsis

Haemorrh

age

Multi

ple organ fa

ilure

Renal failu

re

Stroke

Bladder carc

inoma

Biliary

tract

carc

inoma

Unknown

Pulmonary

Embolis

m

Respira

tory

relate

d

Bowel isch

aemia/o

bstruct

ion

Note: 73 causes of death reported in 63 patients

Comment:

• There were 73 causes of death reported in the

63 audited cases, as some cases have more

than one cause of death attributed to their

case.

• The most common causes of death were

cardiac failure in 15 cases and respiratory

failure in 14, followed by bowel ischaemia/

obstruction (11), intracranial haemorrhage/

brain-stem compression (10) and sepsis (6).

Haemorrhage and multiple organ failure

both had 3 cases, with renal failure, stroke

and unknown aetiology 2 cases, and one

pulmonary embolism.

5.2 establishing cause of death

The cause of death recorded by the treating

surgeon is based on the clinical course of the

patient and any relevant supporting evidence from

investigations. Where doubt exists around the

circumstances leading to a death, the case may be

referred to the Coroner. In other instances, where

the cause of death is not clear, a post-mortem

examination may be requested. This latter method

of confirming cause of death is requested with

decreasing frequency.

Surgeons were asked if the patient was referred

for a post-mortem examination. See Table 3 for

an overview of post-mortems recorded on the 63

audited cases.

Table 3: Overview of post-mortems performed in the ACT

% of patients Post-mortemperformed

43% No

27% Unknown

30% Yes - coroner

Comment:

• 30% (19) of patients had a post-mortem, 43%

(27) did not and, in 27% (17) of cases, this was

unknown.

• The ACT rate of post-mortems is higher than

the national average of 13%.

• Where a post-mortem was not undertaken,

17% (3/18) of surgeons indicated that

they would have preferred to have one

undertaken.

• Where a post-mortem was undertaken, 33%

(6/18) of surgeons had read the report prior

to completing the surgical case form.

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6. proFile oF operaTive inTervenTion

KEY POINTS

• 78% (49/63) of patients had at least one

surgical procedure.

• 77% (51) of procedures were carried

out by a consultant surgeon. In other

cases, the surgery was performed by

registrars or SET trainees, usually in the

presence of a consultant.

• The most common postoperative

complications recorded were aspiration/

pneumonia and cardiac failure.

6.1 operative intervention

78% (49/63) of patients had at least one surgical

procedure during their admission compared with

78% nationally. 11% (7/63) of patients had more

than one operation, with the highest number

of procedures on a single patient being five.

Nationally, 28% of patients had more than one

operation.

• Where an operation was not performed, the

surgeon was asked why. In some cases, there

were multiple reasons given. Overall, in 16%

(10) of cases, the surgeon reported an active

decision not to operate. In 5% (3) of cases,

the patient refused treatment. In a further

5% (3) of cases, there was a decision to limit

treatment, and in 3% (2) of cases, it was not a

surgical problem.

• There were no cases where the procedure was

abandoned upon finding a terminal situation.

6.2 Timing of surgical episodes

The critical nature of a patient’s condition

determines the timing for surgery. Of all operative

episodes in the audit period, 87% (54) were

classified as emergencies, including, 73% (45) who

went to surgery within 24 hours of admission. The

timing of emergency surgical episodes is shown in

Figure 20 below.

Figure 20: Timing of emergency surgical episodes

50

40

30

20

10

0

Cas

es (%

)

Operative urgency by status

Immediate

(less

than 2 hours)

Emergency

(less

than 2 hours)

Scheduled emergency

(Over 2

4 hours post

admission) Electiv

e

Note: N=62; Data not available in 1 case.

6.3 seniority of surgeon operating

The clinician completing the SCF has to record

the seniority of the surgeon who performed the

surgery (as shown in Figure 21 below).

Figure 21: Seniority of operating surgeon by operation number

100

90

80

70

60

50

40

30

20

10

0

Cas

es (%

)

All operations

1st Operation

Subsequent operations

Consultant SET Trainee Registrar

SET: Surgical Education and Training

Note: A total of 66 procedures were performed on 49 patients.

Comment:

• In all operations performed, 77% (51/66) of

procedures were performed by a consultant

surgeon or Fellow, 14% (9/66) of procedures

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were performed by the SET and the remaining

9% (6/66) by the registrar.

• In the first operation for each patient, 71%

(35/49) were performed by a consultant

surgeon or Fellow, 16% (8/49) by the SET and

10% (5/49) by a registrar (not indicated in one

case).

• In the 18 subsequent operations, 88% (16/18)

were performed by a consultant surgeon or

Fellow, 6% (1/18) by the SET and 6% (1/18) by

a registrar.

• No operations in the audit group were

undertaken by an international medical

graduate (IMG) or general practitioner.

• All surgical procedures were attended by an

anaesthetist.

6.4 postoperative complications

Surgeons were asked to report on definable

postoperative complications. The following chart

shows the complications experienced and the

numbers of cases involved (see Figure 22).

Figure 22: Frequency of postoperative complications

20

18

16

14

12

10

8

6

4

2

0

Tissue isc

haemia

Wound bre

akdown

Renal failu

re

Procedure

relate

d sepsis

Postoperativ

e bleeding

Pulmonary embolis

Liver failu

re

Multi org

an failu

re

Cerebro

vascular accident

Respira

tory/asp

iratio

n

Cardiac fa

ilure

Complication

Cas

es (%

)

Note: N=37 complications in 20 cases.

Comment

• 32% (20) of patients had at least one

postoperative complication which compares

with 33% nationally.

• The most common postoperative

complications were aspiration/respiratory

issues and cardiac failure.

• 11% (7) of patients had an unplanned

return to theatre which compared with 16%

nationally.

6.5 anaesthetic problems

Surgeons were asked whether there was a problem

with the anaesthetic component of the surgery.

In 94% (46/49) of cases reported no anaesthetic

issues. There were no cases in which surgeons felt

that there definitely was an anaesthetic problem;

however, in 6% (3/49) of cases, the surgeon

indicated that there was possibly an anaesthetic

problem. This compares with national figures

where 6% reported that there was definitely or

possibly an anaesthetic problem.

ANZCA have indicated an interest in participating

in the audit process in the future, which will enable

these cases to be referred to an anaesthetist for

review.

6.6 Transfers between hospitals in the aCT and nsW

Twenty-one out of 63 (33%) patients were

transferred between hospitals during their episode

of care, both from other hospitals within the

ACT and interstate from NSW. No patients were

transferred from an ACT private hospital to an ACT

public hospital during their care.

Cases in ACTASM include those patients

transferred from interstate where there is no

jurisdiction to obtain the associated case notes and

information. Therefore, should an assessor decide

that the interstate area of care could provide an

opportunity for lessons to be learned, the case is

referred to the Collaborating Hospitals Audit of

Surgical Mortality (CHASM) managed in NSW by the

Clinical Excellence Commission. This ensures that

appropriate agreement has been given, right to

reply is offered and the lessons learned reach the

required destinations to promote improvements in

patient care.

As a measure of the quality of the ‘clinical

handover’ between hospitals, surgeons are

asked to report on any delays or problems, the

appropriateness of the transfer, appropriateness

of the level of care delivered, and if sufficient

information was provided in the handover

documentation.

Surgeons are asked to record any issues associated

with the transfer of patients between hospitals

(see Figure 23).

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Figure 23: Type of issues associated with patient transfers

18

16

14

12

10

8

6

4

2

0

Tran

sfer

issu

es (%

)

Inappropria

te le

vel

of care

Insuffi

cient clin

ical

documentation

Transfer D

elay

Problems d

uring

transfe

r

Note: N=8 issues in 21 transfers.

Comment:

• 33% (21/63) of patients were transferred

during their episode of care compared with

28% nationally.

• Eight issues in total of five patients were

raised in relation to the transfer. In some

cases, there was criticism of more than

one aspect of the transfer. Thus, 24% of

transferred patients had some form of

transfer issue. This figure is less than the

nationally reported rate of 37%.

• The most frequent issues raised were transfer

delay (17%), inappropriate level of care and

insufficient clinical documentation (both at

11%), and problems during the actual transfer

(5%).

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7. peer revieW ouTComes

KEY POINTS

• In 13% (8) of cases surgeons indicated

they would change some aspect of

clinical care on review.

• In 95% (60/63) of cases, assessors

identified either no issues or minor

issues in clinical management.

• In 5% (3/63) of cases, assessors

identified an area of concern or an

adverse event.

• Overall, assessors identified 16 areas

for clinical improvement in 12 cases,

including a change in surgical approach

(6%) and issues with preoperative

transfer (5%).

7.1 surgeon retrospective review

During the peer review process, surgeons

are asked to critically review the case and ask

themselves: ‘In retrospect, would you have done

anything differently?’ In14% (9/63) of cases,

surgeons indicated that they would have done

something differently, although it was identified

that this may not have made a difference to the

outcome. Surgeons’ answers were grouped by

meaning. The most common responses were:

• change the technique or the operation (n=5)

• earlier intervention (n=2)

• earlier transfer and optimisation (n=1)

• reoperate (n=1).

7.2 second-line assessments

The peer-review process is a retrospective

examination of the clinical management of

patients who died whilst under the care of a

surgeon. All assessors (first- and second-line)

must decide if the death was a direct result of

the disease process alone or if aspects of the

management of the patient may have contributed

to the outcome.

The first-line assessor decides if the treating

surgeon has provided enough information to

allow them to reach an informed decision on the

appropriateness of management of the case. If

inadequate information was provided, the first-line

assessor requests a second-line case note review.

Other triggers for requesting SLA are:

• where a more detailed review of the case

could better clarify events leading up to death

and any lessons emanating from the case

under review

• where death was unexpected, for example, in

a young, fit patient with benign disease or in a

day surgery case.

A total of 69 cases had first-line assessments

completed in the audit period; six were referred

for second-line review; however, these were

not completed by the census date. They will be

reported on in the 2013 annual report.

7.3 Clinical management issues

A primary objective of the peer-review process

is determining if death was a direct result of

clinical management issues. There are two

possible outcomes: either the death was a direct

outcome of the disease process and the clinical

management had no impact, or there was a

perception that aspects of patient management

may have contributed to the death of the patient

(See Figure 24).

In making an assessment of contributing factors,

the assessor can choose three options:

• Area of consideration: where the assessor

believes an area of care could have been

improved or different but recognises the

issue is perhaps debatable. It represents a

suggestion regarding treatment options or a

minor criticism.

• Area of concern: where the assessor believes

that an area of care should have been better.

• Adverse event: an unintended injury or event

that was caused by the medical management

of the patient rather than by the disease

process and which was sufficiently serious

to lead to prolonged hospitalisation, or to

temporary or permanent impairment or

disability of the patient, or which contributed

to or caused death.

In addition, there are predetermined outcomes

classified as an adverse event (e.g., anastomotic

leak and pulmonary embolus). It must be

emphasised that an adverse event does not

imply negligence as some adverse events will

occur even with the best of care. For example, a

fatal pulmonary embolism can occur even with

the use of the best deep vein thrombosis (DVT)

prophylaxis. It also must be emphasised that an

adverse event is not necessarily preventable and

may not contribute to the death of the patient.

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Figure 24: Frequency and spectrum of clinical management issues recorded per patient as recorded by assessors

90

80

70

60

50

40

30

20

10

0

Spectrum of clinical management issues

Cas

es (%

)

Consideratio

n

Concern

No issues

Adverse event

Note: N= 67 events associated with 63 cases

Comment:

• In 81% (51) of cases, no issues of clinical

management were identified. When this is

combined with areas of consideration (13

instances in 9 cases), 95% (60) of cases had no

or minor criticism. Nationally, these figures

were 74% and 88% respectively.

• If an assessor flags an area of concern or

adverse event, this implies a greater degree of

criticism of clinical management. In this series,

this occurred in 5% (3) of audited deaths

compared with 13% of cases nationally.

7.3.1 Perceivedimpactofclinicalmanagementissues

First- and second-line assessors have to indicate:

1. what impact any perceived issues of patient

management might have had on the clinical

outcome, and

2. whether or not these issues were preventable.

First- and second-line assessors may identify more

than one issue of clinical management in each

patient under review. It is important, therefore,

that the impact of any of these criticisms on

an individual patient’s outcome is analysed

and compared. In the tables below, all patients

associated with an area of consideration, concern

or adverse event are represented. Tables in

this section show data that are patient-focused

rather than incident-focused. Table 4 looks at the

preventability and outcomes for the clinical issues

reported.

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Note: some cases have more than one clinical management issue and the most serious incident is used for each case N=67 events associated with 63 cases.

Comment:

In total, 16 clinical incidents were identified, with 5% (3) of all cases reporting incidents viewed as serious.

• One of these cases was attributed to care received in a regional hospital prior to transfer. This information has been forwarded to CHASM for review.

• One case was attributed to another clinical team within the hospital. Deidentified feedback has been provided.

• One case was associated with the audited surgical team. The assessor viewed the issue as “probably not preventable”. It was related to multiple associated co-morbidities where treatment of one condition led to deterioration of another.

Another seven issues were considered by assessors to have either ‘probably caused the death’ or which ‘may have contributed to death’ in six patients. All were reported as areas of consideration, that is, the assessor believed an area of care could have been improved or different but recognised that this was an area of debate. Of these cases:

• A further 3 issues were related to treatment at a regional hospital prior to transfer.

• 1 issue was associated with another clinical team within the hospital.

• 1 was related to preoperative assessment

• 2 were related to the individual patients

condition.

Table 4: Perceived impact of clinical issues groups as recorded by assessors

ClinicalIncidents TotalOccurrences(n=63) %ofAuditedSeries

No clinical management issues perceived

51 81%

Clinical management issues perceived

16 issues in 12 cases 19%

Degree of criticism expressed

Clinical management issues (n=16)

NOTE: some cases have more than one clinical management issue

% of Audited Series

NOTE: some cases have more than one clinical management issue

Area of Consideration 13 issues in 9 cases 14%

Area of Concern 2 3%

Adverse Event 1 2%

Data not available 0 0

Perceived impact on outcome

Clinical management issues (n=16) % of Audited Series

Note: some cases have more than one clinical management issue. % is most serious

incident for each case

Did not affect outcome 6 6%

May have contributed to death

5 5%

Probably caused death 5 8%


Preventability of incidents Clinical management issues (n=16) % of Audited Series



Definitely preventable 0 0

Probably preventable 6 6%

Probably not preventable 8 10%

Definitely not preventable 1 2%

Data not available 1 2%

Attribution to clinical specialty

Clinical management issues (n=17)

NOTE: In one case an issue was attributed to two causes

% of Audited Series



Audited team 8 13%

Another clinical team 5 8%

Hospital Issue 1 2%

Other 3 3%


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All surgeons receive individualised feedback on

their cases, including comments from assessors

regarding issues raised, alternative opinions

on treatment options and suggested areas for

improvement.

7.4 improvements in care

Assessors view of improvements in care

Assessors identified areas of management that

they thought could be improved. These included

preoperative care, the decision to operate,

choice of operation and the intraoperative and

postoperative management (see Figure 25).

Figure 25: Assessors perception of areas of clinical management that could be improved

40

35

30

25

20

15

10

5

0

Perc

enta

ge o

f ca

ses

(%)

Management improvement area

Operation Choice

Operation Tim

ing

Intraoperativ

e

Surgeon’s E

xperience

Postoperativ

e

Pre O

perative

Opertion D

ecision

Note: 16 issues identified in 12 patients.

Comment:

• In 13% (2) of the issues raised, assessors

considered there could have been

improvement in preoperative care. These

were related to preoperative investigation

and delay in referral to surgical team.

• In 25% (4) of the issues raised, assessors

considered there could be a change in surgical

approach. This individualised feedback was

provided to the surgeon involved. In one

case (2%), the assessor considered that the

consultant surgeon should have provided

earlier decision making support to junior staff.

• 6% (1) of issues had a delay related to the

patient.

• 6% (1) of issues were related to surgeons

experience level.

• 19% (3) of issues raised were in preoperative

transfer (discussed further at 6.6).

• The 19% (3) issues relating to postoperative

care all occurred in the same patient. This was

related to treatment of the individual patient’s

multiple comorbidities, and this feedback has

been provided to the surgeon involved.

• The 13% (2) ‘Other’ issues raised were related

to a clinical team other than the audited team.

Surgeonsviewofimprovementsincare

Surgeons were asked “In retrospect, would you

have done anything differently?” In eight of the 63

cases (13%), surgeons considered that if faced with

the same situation, they would have changed their

management of patient care. This emphasises the

value of the reflection-on-practice aspect of the

audit, providing the surgeon with a focus to review

each patient’s episode of care and to identify

opportunities for improvements in patient care

(see Figure 26).

Figure 26: Surgeons perception of areas of clinical management that could be improved

6

5

4

3

2

1

0

Areas for Clinical Management Improvement

Cas

es (%

)

Preoperativ

e Care

Choice of operatio

n

Surgical S

upervision

Comment:

• In 3% (2/63) of cases, the surgeon would have

changed preoperative care. In one case, earlier

patient optimisation and surgery, and in the

other, repeat diagnostic intervention.

• In 8% (5/63) of cases, the surgeon would have

used a different surgical approach.

• In 2% (1/63) of cases, the surgeon felt he

or she would provide closer supervision in

surgical decision-making.

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8. ConClusions

This is the second annual report for ACTASM.

• The majority of patients in the audit were

emergency admissions, with at least one co-

morbidity.

• The ASA rating of 4 or greater increased

from 52% last year to 63% this year, which

is comparable to the national average.

This result confirms the ACT Management

Committee view that the 2010 data may have

been skewed due to small numbers in the

initial year of data collection. This trend will

again be reviewed in the 2013 report.

• 85% (53/62) of cases were assessed as having

had appropriate venous thromboembolism

(VTE) prophylaxis. In only one case did the

assessor believe that the VTE prophylaxis was

not appropriate, with 13% unknown.

• 57% (36/63) of patients received care in a

critical care unit. In the 42% cases where the

patient did not go to ICU, reviewers identified

that the patient may have benefited from it in

one (4%) case.

• Fluid balance in the surgical patient is an

ongoing challenge. In this series, 3% (2)

of cases were perceived to have had poor

management of fluid balance. In 20% (12)

of cases, the assessor felt the fluid balance

status was unknown.

• In 13% (8) of cases surgeons indicated they

would change some aspect of clinical care on

review.

• In the majority of cases, assessors believed

that the patient had received appropriate

care, with 95% having either no issues, or

minor issues in clinical management.

• In 5% (3) of cases, assessors identified an area

of concern or an adverse event. This compares

favourably with nationally reported figure of

13%.

• Assessors identified 16 areas for clinical

improvements in 12 cases, including a change

in surgical approach (6%) and issues with

preoperative transfer (5%).

• Participation rate among surgeons and

hospitals in the ACT continues to be high, at

99% and 100% respectively.

• RANZCOG commenced participation in the

audit this year.

aims For 2013:

• Increase surgeons participation as assessors to

80% by the end of 2013.

• Increase participation by RANZCOG fellows to

90% by the end of 2013.

• Decrease response times for surgical case

forms for outliers. Target of less than 45 days.

• Identify improvements to the Fellows

Interface to make it more user friendly, to

increase its utilisation.

• Continue to contribute data to ANZASM and

National Case Note Review Booklets. Develop

ACT Clinical Case Note Review Booklet in

collaboration with a larger state.

• Include participation of anaethetists in

ACTASM.

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9. aCKnoWledgmenTs

The Australian Capital Territory Audit of Surgical

Mortality acknowledges the support and assistance

of many individuals and institutions that have helped

in the continuation and development of this project,

including:

• all participating surgeons

• all first-line assessors

• all second-line assessors

• medical records, safety and quality and risk

management departments in all participating

hospitals

• ACT Health for funding and ongoing support, in

particular Sonia Hogan for advice and editing

• the state Project Managers, in particular Sasha

Stewart from the South Australian Audit of

Perioperative Mortality for assistance with data

preparation for this report

• the Royal Australasian College of Surgeons,

Division of Research, Audit & Academic Surgery

staff, particularly

> Professor Guy Maddern

Chair, ANZASM Steering Committee

> A/Prof Wendy Babidge

Director, RAAS Division

> Mr Gordon Guy

ANZASM Manager

actasm management committee membership

Dr John Tharion Clinical Director, ACTASM,

Australasian Society of Cardiac &

Thoracic Surgeon

Dr Alexander Burns Australian Orthopaedic

Association

Dr Phillip Jeans General Surgeons Australia

Dr Tuan Pham Australian & New Zealand Society

of Otolaryngology Head & Neck

Surgery

Dr David McDowell Neurosurgical Society of

Australasia

Dr Chandra Patel Plastic surgeon

Dr David Hardman Vascular surgeon

Dr Morris Mulcahy Urological Society of Australia

and New Zealand

Dr Stephen Robson Royal Australian and New

Zealand College of Obstetricians

and Gynaecologists

Dr Carmel McInerney Australian and New Zealand

College of Anaesthetists

Ms Libby Trickett ACT Government, Health

Directorate Representative

Ms Veronica Walker Project Manager

Telephone: +61 2 6285 4558

Facsimile: +61 2 6285 3366


Address: 3/13 Napier Close Deakin ACT 2600 Australia

Web: www.surgeons.org/actasm

ACTASM ANNUAL REPORT 2012ACT Audit of Surgical Mortality

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