cec's chasm program report july 2009-december 2010 · title: collaborating hospitals’ audit...

Program ReportJuly 2009 – December 2010

Royal Australasian College of Surgeons

© Clinical Excellence Commission 2012

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced without prior written permission from the Clinical Excellence Commission (CEC). Requests and inquiries concerning reproduction and rights should be addressed to the Director, Corporate Services, Clinical Excellence Commission, Locked Bag A4062, Sydney South NSW 1235 or email [email protected]

Title: Collaborating Hospitals’ Audit of Surgical Mortality (CHASM) Program Report, July 2009 – December 2010ISSN: 2201-2923 SHPN: (CEC) 120399

Suggested citationClinical Excellence Commission (CEC) 2012. Collaborating Hospitals’ Audit of Surgical Mortality (CHASM) Program Report, July 2009 – December 2010. Sydney: CEC

Clinical Excellence Commission Chair, CEC Board: A/Prof Brian McCaughan, AMChief Executive, CEC: Prof Clifford F Hughes, AOChair, CHASM: A/Prof Michael Fearnside, AMDeputy Chair, CHASM and Chair, NSW State Committee, Royal Australasian College of Surgeons: Dr Joseph Lizzio

Any enquiries about or comments on this publication should be directed to:

Paula ChengManager, Special CommitteesClinical Excellence CommissionLocked Bag A4062Sydney South NSW 1235

Phone: (02) 9269 5543Email: [email protected]

mailto:[email protected]


Program ReportJuly 2009 – December 2010

iv | CHASM PROGRAM REPORT 2009-2010

CHASM PROGRAM REPORT 2009-2010 | 1

ContentsAbbreviations ....................................................................................................................................7

Chairman’s report .............................................................................................................................9

CHASM membership from July 2009 to December 2010 .................................................................10

Executive summary .........................................................................................................................11

Objectives .......................................................................................................................................12

1 Introduction .................................................................................................................................13

1.1 Background ..........................................................................................................................13

1.2 Project governance ...............................................................................................................14

1.2.1 CHASM committee .....................................................................................................................14

1.2.2 CHASM project team ..................................................................................................................15

1.3 The audit process .................................................................................................................15

1.3.1 Audit inclusion and exclusion criteria ...........................................................................................15

1.3.2 Methods .....................................................................................................................................15

1.3.3 Data management and analysis ...................................................................................................18

2 Audit participation .......................................................................................................................19

2.1 Surgeon participation ...........................................................................................................19

2.1.1 By surgical specialty .................................................................................................................... 20

2.1.2 By former area health services (AHS) ...........................................................................................21

3 Audit progress .............................................................................................................................22

3.1 By surgical specialty ..............................................................................................................23

3.2 By former area health services ..............................................................................................25

3.3 Discussion ............................................................................................................................27

Part A - SURGICAL SPECIALTY FIGURES ............................................................................................................................................... 29

4 Surgical specialty findings .................................................................................................................................................................................... 30

4.1 Demographics .....................................................................................................................................................................................................31

4.1.1 Age and sex distribution .....................................................................................................................................................................31

4.2 Admissions .............................................................................................................................................................................................................31

4.2.1 Confirmed surgical diagnoses........................................................................................................................................................ 33

4.3 Transfers .................................................................................................................................................................................................................. 34

4.4 Assessment ........................................................................................................................................................................................................... 35

4.4.1 American Society of Anaesthesiologists (ASA) grades ................................................................................................. 35

2 | CHASM PROGRAM REPORT 2009-2010

4.4.2 Malignancy ................................................................................................................................ 36

4.4.3 Co-morbid factors ..................................................................................................................... 36

4.4.4 Risk of death before surgery ...................................................................................................... 38

4.5 Management .......................................................................................................................40

4.5.1 Operation .................................................................................................................................. 40

4.5.2 Grade of surgeon ...................................................................................................................... 44

4.5.3 Use of high-dependency and intensive care units ....................................................................... 46

4.5.4 Venous thromboembolism (VTE) prophylaxis ............................................................................. 48

4.6 Clinical incidents ..................................................................................................................49

4.6.1 Pre-operative delay or errors ...................................................................................................... 49

4.6.2 Post-operative complications ..................................................................................................... 49

4.6.3 Unplanned return to theatre .......................................................................................................51

4.6.4 Unplanned admission to ICU ...................................................................................................... 52

4.6.5 Unplanned re-admission within 30 days of surgery .................................................................... 52

4.6.6 Hospital infection ...................................................................................................................... 53

4.7 Causes of death ...................................................................................................................53

4.7.1 Post-mortem examination .......................................................................................................... 55

4.8 In hindsight ..........................................................................................................................56

4.8.1 Potential deficiencies of care ...................................................................................................... 58

4.9 Discussion ............................................................................................................................61

Part B – HEALTH SERVICE FIGURES .............................................................................................63

5 Health service results .................................................................................................................. 64

5.1 Demographics ......................................................................................................................65

5.1.1 Age and sex distribution ............................................................................................................. 65

5.2 Admissions ...........................................................................................................................67

5.3 Transfers ..............................................................................................................................68

5.4 Assessment ..........................................................................................................................69

5.4.1 American Society of Anesthesiologists (ASA) grade ................................................................... 69

5.4.2 Malignancy ................................................................................................................................ 70

5.4.3 Co-morbid factors ..................................................................................................................... 70

5.4.4 Risk of death before surgery ...................................................................................................... 72

5.5 Management .......................................................................................................................74

5.5.1 Operation ...................................................................................................................................74

5.5.2 Use of high-dependency and intensive care units ....................................................................... 79

5.5.3 Venous thromboembolic prophylaxis ......................................................................................... 80


5.6 Clinical incidents ..................................................................................................................82

5.6.1 Pre-operative delay or error ........................................................................................................ 82

5.6.2 Post-operative complications ..................................................................................................... 83

5.6.3 Unplanned return to theatre ...................................................................................................... 85

5.6.4 Unplanned admission to ICU ...................................................................................................... 86

5.6.5 Unplanned re-admission within 30 days of surgery .................................................................... 87

5.6.6 Fluid balance .............................................................................................................................. 88

5.6.7 Hospital infection ....................................................................................................................... 88

5.6.8 Areas for improvement .............................................................................................................. 89

5.7 Causes of death .................................................................................................................. 90

5.8 Discussion ........................................................................................................................... 90

APPENDICES

Appendix 1: Terms of Reference ......................................................................................................91

Appendix 2: CHASM staff ...............................................................................................................94

Appendix 3: Surgical Case Form, First-Line and Second-Line Assessment Forms ..............................95

References .................................................................................................................................... 114

TABLES

Table 1: Change in surgeon participation in CHASM between the last and current report periods ..........19

Table 2: Number and proportion of surgeons participating in CHASM by former area health service at 31 December 2010 .............................................21

Table 3: Percentage of SCFs, FLAs and SLAs completed and returned of deaths recorded between 1 July 2009 and 31 December 2010 by surgical specialty ......................23

Table 4: Time taken to return SCFs, FLAs and SLAs of deaths recorded between 1 July 2009 and 31 December 2010 by surgical specialty ....................................24

Table 5: Time taken to return surgical case forms of deaths recorded between 1 July 2009 and 31 December 2010 (n=1940) by former area health services ....................26

Table 6: Change in audit outputs between the last and current reporting periods ..........................27

Table 7: Age and sex distribution of audited deaths (n=1812) .........................................................31

Table 8: Age and admission status of audited deaths .....................................................................31

Table 9: The three most reported confirmed surgical diagnoses of 1812 audited patient deaths by surgical specialty .......................................................................33

Table 10: ASA grades ......................................................................................................................35

Table 11: Types of co-morbid factors in audited deaths by surgical specialty (n=1619) ......................36

Table 12: Comparison of perceived risk of death of audited deaths before surgery between participating surgeons and CHASM assessors ........................................39


Table 13: The three most reported operations (in Read code description) on 1601 audited deaths by surgical specialty ....................................................................42

Table 14: Grade of surgeon and involvement in three operations performed on audited deaths .......................................................................................... 44

Table 15: Reported use of intensive care unit or high-dependency unit in audited deaths by surgeons’ perceived risk of death before surgery and operative status (n=1812) .................................................................................................47

Table 16: Ten most reported causes of death, based on Read code description, in 1718 audited deaths ..........................................................................53

Table 17: Five most reported causes of death, based on Read code description, for audited deaths with age under 70 years and 70 years or more ....................................54

Table 18: Three most reported causes of death, based on Read code description, by surgical specialty ......................................................................55

Table 19: Level of agreement between participating surgeons’ self-assessment and CHASM assessors’ evaluation on a number of areas relating to patient management ...................................................................................................57

Table 20: The description and frequency of the top 12 preventable deficiencies of care identified by CHASM assessors in 1812 audited patient deaths .............................58

Table 21: Change in surgical management of audited deaths as reported by surgeons and assessors over two 18-month periods up to 31 December 2010 .....................62

Table 22: Median age and sex of audited deaths by former area health service (n=1812) .................65

Table 23: Age group and sex distribution of audited deaths by former area health service (n=1812) ..................................................................................66

Table 24: Co-morbid factors in audited deaths by former area health service (n=1619) ....................70

Table 25: Proportion of audited deaths with consultant surgeons’ involvement in three operations performed by former area health service .........................77

Table 26: Reasons for pre-operative delay or error in confirmation of surgical diagnosis by former area health service (n=165)....................................................82

Table 27: Unit associated with pre-operative delay or errors in confirmation of surgical diagnosis by former area health service (n=165) ................................................82

Table 28: Description of post-operative complications by former area health service (n=573) ........... 84

Table 29: Reported infection in audited deaths by former area health service (n=1812) .....................88

Table 30: Proportion of audited deaths for three most reported areas of patient management which could have been improved at each former area health service (n=679) ....................89

Table 31: Five most reported cause of death, based on Read code description, by former area health service (n=1718) .......................................................... 90


FIGURES

Figure 1: CHASM project governance structure ..............................................................................14

Figure 2: CHASM process ...............................................................................................................17

Figure 3: Number of surgeons participating in CHASM by surgical specialty at 31 December 2010 ......................................................................................................20

Figure 4: Proportion of active RACS fellows participating in CHASM in NSW by surgical specialties at 31 December 2010 ........................................................20

Figure 5: Summary of the CHASM audit process from 1 July 2009 to 31 December 2010 ...............22

Figure 6: Response to surgical case forms sent for 3351 recorded deaths between 1 July 2009 and 31 December 2010 by former area health service .....................25

Figure 7: Admission types of audited deaths by surgical specialty (n=1812) .....................................32

Figure 8: Pre-operative transfer of audited deaths by surgical specialty (n=1812) ............................34

Figure 9: Distribution of audited deaths by ASA grade and surgical specialty (n=1812) ...................35

Figure 10: Surgeons’ perceived risk of death before surgery of audited deaths by surgical specialty (n=1812) ..............................................................................38

Figure 11: Distribution of audited deaths by operative status and perceived risk of death before surgery (n=1812) ..............................................................................39

Figure 12: Distribution of audited deaths by operative status and surgical specialty (n=1812) ..............40

Figure 13: Distribution of audited deaths by admission and operative status (n=1812) .....................41

Figure 14: Distribution of audited deaths with an operation by admission type and timing of first operation (n=1573) ....................................................................43

Figure 15: Proportion of audited operative deaths of which the consultant surgeon was in theatre for at least one operation by admission type and surgical specialty (n= 1601) ..................45

Figure 16: Proportion of audited deaths with reported use of intensive care unit or high-dependency care unit by surgical specialty (n=1812) ....................................46

Figure 17: Distribution of audited deaths by use of VTE prophylaxis and surgical specialty (n=1812) ...................................................................................... 48

Figure 18: Proportion of audited deaths with post-operative complications by surgical specialty and admission type (n=1567) ..........................................................50

Figure 19: Distribution of audited operative deaths with an unplanned return to theatre by admission type and surgical specialty (n=1567) ................................51

Figure 20: Distribution of audited deaths with an unplanned admission to ICU by admission type and surgical specialty (n=1778) ...............................................52

Figure 21: Proportion of audited deaths with potential preventable deficiency of care identified by CHASM assessors by surgical specialty (n=1812) ..............................60

Figure 22: Admission types of audited deaths by former area health service (n=1812) .....................67

Figure 23: Pre-operative transfer of audited deaths by former area health service (n=1812) .............68

Figure 24: Distribution of audited deaths by ASA grade and former area health service (n=1812) ....69


Figure 25: Presence of malignancy in audited deaths by former area health service (n=1812) ...........70

Figure 26: Perceived risk of death before surgery of audited deaths by former area health service (n=1812) ................................................................72

Figure 27: Distribution of audited operative deaths by perceived risk of death before surgery and former area health service (n=1601) ....................................73

Figure 28: Distribution of audited deaths by operative status and former area health service (n=1812) .........................................................................74

Figure 29: Distribution of audited deaths with elective admissions by operative status and former area health service (n=274) .............................................74

Figure 30: Distribution of audited deaths with emergency admissions by operative status and former area health service (n=1504)...........................................75

Figure 31: Timing of first operation of audited deaths with elective admissions by former area health service (n=267) ...........................................................75

Figure 32: Timing of first operation of audited deaths with emergency admissions by former area health service (n=1301)..........................................................76

Figure 33: Distribution of audited deaths with elective admissions and consultant surgeons in theatre for at least one operation by former area health service (n=267).............................................................................78

Figure 34: Distribution of audited deaths with emergency admissions and consultant surgeons in theatre for at least one operation by former area health service (n= 1301) ..........................................................................78

Figure 35: Use of intensive care or high-dependency unit in audited deaths by operative status and former area health service (n=1812) ................................79

Figure 36: Use of intensive care or high-dependency unit in audited deaths by surgeons’ perceived risk of death before surgery and former area health service (n=1812) .........................................................................80

Figure 37: Use of VTE prophylaxis in audited deaths by former area health service (n=1812) ............... 80

Figure 38: Type of VTE prophylaxis used by former area health service (n=1473) .............................81

Figure 39: Reasons for not using VTE prophylaxis by former area health service (n=339) .................81

Figure 40: Proportion of audited operative deaths with post-operative complications by admission type and former area health service (n=1568) ......................83

Figure 41: Distribution of audited operative deaths with an unplanned return to theatre by admission type and former area health service (n=1568) ..................85

Figure 42: Distribution of audited operative deaths with an unplanned admission to ICU by admission type and former area health service (n=1778) .................86

Figure 43: Distribution of audited deaths with an unplanned readmission within 30 days by admission type and former area health service (n=1812) .....................87

Figure 44: Distribution of audited deaths with a reported issue in fluid balance by former area health service (n=1812) ..............................................................88


AbbreviationsAHS Area Health Services

ANZASM Australian and New Zealand Audit of Surgical Mortality

CAM Clinical Audit Managers

CEC Clinical Excellence Commission

CHASM Collaborating Hospitals’ Audit of Surgical Mortality

DVT Deep Venous Thrombosis

FLA First-Line Assessment

HDU High-Dependency Unit

ICU Intensive Care Unit

LHD Local Health Districts

RACS Royal Australasian College of Surgeons

SASM Scottish Audit of Surgical Mortality

SCF Surgical Case Form

SCIDAWS Special Committee Investigating Deaths Associated With Surgery

SCIDUA Special Committee Investigating Deaths Under Anaesthesia

SLA Second-Line Assessment


Chairman’s report

This second report of the Collaborating Hospitals’ Audit of Surgical Mortality (CHASM) covers the

18 month period from July 2009 to December 2010. Subsequent reports will be annualised and will

provide data referable to the new local health districts.

During this period, case reporting and surgeon participation steadily increased. In subsequent years,

there has been a further increase in the participation rate due in part to the Royal Australasian

College of Surgeons (RACS) mandating participation in a state-based audit of surgical mortality

(CHASM) for surgeons to satisfy the continuing professional development requirements of the RACS.

We have reported the audit data by surgical specialty (Part A) and by health service (Part B).

As previously, deaths associated with surgical care generally occur in an elderly population

with substantial co-morbidities. We have selected twelve indicators to track changes in clinical

management and in the future, an analysis of these trends will be provided.

CHASM is an educational process which aims to improve surgical care through reflective learning,

by providing individual comment on clinical management of patients by a peer surgeon. In

NSW, CHASM is managed jointly by the NSW State Committee of the RACS and the Cinical

Excellence Commission.

This report is available on the Clinical Excellence Commission website at

http://www.cec.health.nsw.gov.au/programs/chasm

MICHAEL R FEARNSIDE AM CLIFFORD F HUGHES AO Chairman CHASM Chief Executive Officer Clinical Excellence Commission

http://www.cec.health.nsw.gov.au/programs/chasm


CHASM membership July 2009 to December 2010

• A/Prof Michael Fearnside, AM, Chair

• Dr Joseph Lizzio, Deputy Chair and Chair of the NSW State Committee of the Royal Australasian College of Surgeons (RACS)

• Dr Allysan Armstrong-Brown, anaesthetist

• Dr Graham Beaumont, human factors safety specialist

• Prof Belinda Bennett, Professor of Health and Medical Law

• Dr Lewis Chan, urologist

• Prof Stephen Deane, general and trauma surgeon

• Prof Anthony Eyers, colorectal surgeon

• Dr Charles Fisher, vascular surgeon

• Dr Hamish Foster, general surgeon

• Dr Warren Hargreaves, general surgeon

• Dr Kim Hill, Director, Clinical Governance

• Prof John Hilton, forensic pathologist

• Prof Clifford Hughes, AO, CEO CEC, ex-officio

• Dr Michael King, general surgeon

• Dr Hugh Martin, AM, paediatric surgeon

• Dr Charles Pain, Director, Health Systems Improvement

• Prof Allan Spigelman, surgical oncologist

• Dr Warwick Stening, neurosurgeon

• Dr Mauro Vicaretti, vascular surgeon

• Dr Shane Waddell, orthopaedic surgeon

• A/Prof Peter Zelas, OAM, colorectal surgeon


Executive summaryThe Collaborating Hospitals’ Audit of Surgical Mortality (CHASM) is an independent peer review audit of deaths of patients, who were under the care of a surgeon at some time during their hospital stay in NSW, regardless of whether an operation was performed. It is funded by NSW Health, administered by the Clinical Excellence Commission (CEC), and co-managed by the NSW State Committee of the Royal Australasian College of Surgeons (RACS). Its audit methodology is based on the Scottish Audit of Surgical Mortality1 developed in 1994 and similar to the other surgical mortality audits being implemented in Australia under the Australian and New Zealand Audit of Surgical Mortality (ANZASM) framework. CHASM is a partner of ANZASM, which is a bi-national framework of regionally-based audits of surgical mortality established by RACS.

This is the second CHASM report. It presents data collected from 1 July 2009 to 31 December 2010. The audit findings are reported in two parts, part A on the NSW aggregated figures by surgical specialty and part B by the former area health services (AHS).

During this reporting period, CHASM recorded the deaths of 3351 patients who were at some time under the care of a surgeon in a hospital. There were approximately 580 000 hospitalisations by 11 surgical service-related groups2 in NSW in the same period.

Participation in ANZASM, i.e., CHASM in NSW, is a requirement for re-certification through the Continuing Professional Development Program of the RACS, if a surgeon is in operative-based practice, has a surgical death and an audit of surgical mortality is available in the surgeon’s hospital. By the end of December 2010, 798 of 1483 (53.8%) active fellows in NSW were participating in CHASM. All information collected by CHASM is protected by legislation, as stipulated in Section 23 of the Health Administration Act 1982.

Between 1 July 2009 and 31 December 2010, CHASM completed the audit of 1812 patient deaths. A summary of the audited deaths is as follows:

• 975 (53.8%) were males and 837 (46.2%) females

• Most were elderly, with a median age of 77 years (interquartile range, 66-85 years)

• 1504 (83.0%) were admitted to hospital because of an emergency

• 1300 (71.7%) had an ASA3 grade of either 3 or 4, that is, they were suffering either a moderate or severe systemic disease that limited function or was a threat to life

• 1072 (59.2%) were at considerable or expected risk of death before surgery

• 1619 (89.3%) had co-morbid factors such as cardiovascular, age and respiratory conditions, that increased the risk of death

• 1601 (88.4%) had at least one operation.

A total of 2194 operations were performed. Consultant surgeons made the decision to operate in 1904 (86.8%) and performed 1288 (58.7%) of them. Many of the audited deaths (1232, 68.0%) had care at intensive care or high-dependency unit. The majority of audited deaths (1473, 81.3%) also had venous thromboembolism prophylaxis.

1 http://www.sasm.org.uk2 Cardiothoracic surgery, colorectal surgery, upper GIT surgery, neurosurgery, ENT & head and neck, orthopaedics, ophthalmology, plastic and

reconstructive surgery, urology, vascular surgery and non-sub-specialty surgery. Data reported in Health Statistics NSW – Admitted Patient Report 2012.

3 American Society of Anesthesiologists Physical Status Classification System.

http://www.sasm.org.uk


Surgeons reported:

• pre-operative delay or errors in confirmation of main surgical diagnosis in 165 (9.0%) audited deaths

• a definable post-operative complication in 573 (31.6%) audited deaths

• unplanned return to theatre in 250 (15.6%) audited deaths

• unplanned admission to intensive care unit in 321 (17.7%) audited deaths

• unplanned re-admission within 30 days of surgery in 65 (3.6%) audited deaths.

Most of the audited deaths (1359, 75.0%) did not have any deficiency of care. In 453 (25.0%) deaths that were under the care of 259 surgeons, however CHASM peer assessors identified 663 potential deficiencies of care, with 386 (58.2%) considered as definitely or probably preventable.

CHASM has selected 12 indicators to track changes in the clinical management of audited deaths as reported by surgeons and assessors. There was a statistical difference in the data of two indicators between this and the last reporting period. In this period, the proportion of audited deaths in which the patient had:

• elective surgery performed as planned, is 9.2 per cent more than in the last period. This difference is statistically significant, χ²(1, N=359) = 9.397, p=0.002

• prophylaxis against venous thromboembolism, is 8.7 per cent more than in the last period. It is also statistically significant, χ²(1, N=2497) = 22.684, p=0.000.

ObjectivesOver the next 12 months, CHASM will:

• Ensure timely notification of deaths and support for participating surgeons in local health districts

• Increase the participation rate of surgeons

• Improve the turnaround time for first- and second-line assessments to provide more timely feedback to participating surgeons

• Continue to provide an annual individual and confidential report to each participating surgeon, with comparative data to peer group and all NSW surgeons

• Continue to publish an annual casebook with a clinical theme for surgical learning

• Examine potential deficiencies of care identified by CHASM assessors and report regularly to the CHASM committee on factors considered preventable or contributory

• Contribute de-identified, aggregated data to the RACS national audit (ANZASM)

• Contribute de-identified, aggregated data to the development of clinical guidelines on patient safety.


1. Introduction This is the second report of the Collaborating Hospitals’ Audit of Surgical Mortality (CHASM) program. It presents the program’s participation data, the audit outputs and the findings on notified deaths that completed the audit between 1 July 2009 and 31 December 2010. The audit findings are reported in two parts, part A on the NSW aggregated figures by surgical specialty and part B by the former area health services (AHS).

KEY POINTS

• CHASM is an independent and systematic peer review audit of surgically-related deaths in NSW.

• This report covers the period from 1 July 2009 to 31 December 2010.

• The audit process involves completion of a questionnaire by the surgeon and an assessment of the completed and de-identified questionnaire by a peer surgeon, followed, if necessary, by a more detailed review of the case notes by another peer surgeon.

• The objectives of CHASM are to inform, educate, facilitate change and improve practice. It achieves this by providing feedback to surgeons, hospitals and the community.

1.1 BackgroundCHASM is an independent and systematic peer review audit of surgically-related deaths in NSW. It is funded by NSW Health, administered by the Clinical Excellence Commission (CEC), and co-managed by the NSW State Committee of the Royal Australasian College of Surgeons (RACS).

At the national level, CHASM is a partner of the Australian and New Zealand Audit of Surgical Mortality (ANZASM), a bi-national framework of regionally-based audits of surgical mortality. ANZASM was formed by the RACS in 2005 and is comprised of the following regional audits:

• Australian Capital Territory Audit of Surgical Mortality

• CHASM of NSW, which is managed by the CEC and maintains membership within ANZASM

• Queensland Audit of Surgical Mortality

• Northern Territory Audit of Surgical Mortality

• South Australian Audit of Peri-operative Mortality

• Tasmanian Audit of Surgical Mortality

• Victorian Audit of Surgical Mortality

• Western Australian Audit of Surgical Mortality

CHASM is designed to identify system and process errors for ongoing improvement and educational purposes. Its audit methodology is based on the Scottish Audit of Surgical Mortality developed in 1994 and similar to the other surgical mortality audits being implemented under the ANZASM framework in Australia.


1.2 Project governanceThe governance structure of CHASM is illustrated in Figure 1. CHASM is overseen by a committee, which was appointed by the Minister for Health under Section 20 of the Health Administration Act 1982. The committee is empowered with specially privileged information under Section 23 of the same act to protect the confidentiality of the information collected for CHASM. This legislative arrangement derives from the previous surgical mortality audit program in NSW (Special Committee Investigating Deaths Associated With Surgery (SCIDAWS)).

As a partner of ANZASM, CHASM also has the protection provided by the Commonwealth Qualified Privilege Scheme under Part VC of the Health Insurance Act 1973 (Gazetted 6 November 2006).

Figure 1: CHASM project governance structure

NSW State Committee of Royal Australasian College

of Surgeons (RACS)

Australian New Zealand Audit of Surgical Mortality

(ANZASM) of RACS

NSW Minister for Health

Clinical Excellence Commission

NSW Participating Surgeons

NSW Ministry for Health

CHASM Committee

CHASM Secretariat

Clinical Audit Managers at Local Health Districts

1.2.1 CHASM committee

Between July 2009 and December 2010, the CHASM committee had 22 members, who were appointed by the NSW Minister for Health. The committee’s terms of reference is at Appendix 1.

The CHASM membership was established following consultations with the NSW State Committee of the RACS. All committee members have expertise in clinical research and audit projects. They have actively contributed to the development and implementation of CHASM since its commencement in January 2008.


1.2.2 CHASM project team

A project team based at the CEC provides secretarial and data management support for CHASM. In addition, clinical audit managers (CAM) or other designated staff at local health districts (LHD) and St Vincent’s Health, provide local support to surgeons and the CHASM program. These staff members are primarily responsible for notifying deaths to CHASM and assisting surgeons and the project team with accessing medical notes throughout the audit process. These local positions are unique to the CHASM program. They have helped overcome the geographical vastness and operational complexity for the transmission of data, information and medical notes throughout the audit process.

A list of the project staff is shown at Appendix 2.

1.3 The audit process

1.3.1 Audit inclusion and exclusion criteria

CHASM engages surgeons, hospitals and the LHD in reporting “deaths that occur within 30 days after an operation, or during the last hospital admission under the care of a surgeon, or where a surgeon had major input to care, irrespective of whether an operation has been performed or not”. If a patient is admitted under the care of a physician and subsequently undergoes an operative procedure, the case is included in the audit process. Terminal care cases are excluded from the full audit process4, and recorded deaths that have been incorrectly attributed to surgical care are abandoned5.

CHASM includes all surgical specialties6 except obstetric deaths, which are involved in another Statewide audit program.

1.3.2 Methods

When a death is reported to CHASM, the project team sends a self-administered questionnaire (surgical case form (SCF)) to the consultant surgeon, who cared for the patient, to collect information about the reported death. The SCF contains questions about the patient’s admission, pre-operative physical status, pre-operative care and complications, details of the operation(s) performed, and post-operative management and complications. Surgeons are also asked to report any potential deficiency of care against the following criteria, and give an opinion on the impact of the deficiency on the patient’s death, and whether the deficiency was preventable:

• Area for consideration – where the clinician believes an area of care could have been improved or been 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 – an unintended ‘injury’ caused by medical management, rather than by the disease process, and is sufficiently serious to:

• lead to prolonged hospitalisation

• lead to temporary or permanent impairment or disability of the patient at the time of discharge

• contribute to or cause death.

4 Terminal care cases do not undergo assessment, but the death is included in the total number of recorded deaths.5 Abandoned cases are deleted records in the database and are not included in the total number of recorded deaths.6 Gynaecological deaths have been included in CHASM since October 2012.


The completed SCF is then assigned to a peer surgeon practising in the same specialty, but at another LHD for first-line assessment (FLA). The first-line assessor examines the information provided in the SCF, from which identifiers have been removed and ascertains any possible deficiencies of care in the reported death, against the above-mentioned criteria and provides an opinion on the incident.

The first-line assessor also determines if the case should proceed to case note review, which is the second-line assessment (SLA). As this involves examination of the case notes, the SLA is not de-identified. Most reported deaths complete the audit process after FLA. About ten per cent of the reported deaths, however, proceed to SLA, due to insufficient information in the SCF or possible deficiencies of care being identified.

The second-line assessor, a different peer surgeon from the FLA, but practising in the same specialty at another LHD, is provided with the patient’s medical notes, and the completed SCF and FLA report, to review the surgical care provided, identify any possible deficiencies of care in the death against the above-mentioned criteria and compile a case summary report for feedback to the treating surgeon.

A copy of the SCF, FLA and SLA forms are shown at Appendix 3.

All surgeons who have completed a SCF are provided a feedback letter on the care and management of the reported death. In addition, participating surgeons will also receive an individual annual report of all notified deaths under their care during the reporting period.

The following outlines the key audit processes undertaken by CHASM.

i. Notification of deaths. CAM or their equivalents at LHD provide fortnightly or monthly notifications of surgical deaths to CHASM. CHASM then sends a self-administered questionnaire (SCF) to the consultant surgeon to request information about the death. Consultant surgeons also may notify the CHASM office directly of deaths that have occurred under their clinical care by completing a SCF, which is available from the CHASM office or website and from CAM or equivalent staff at LHD.

ii. At the CHASM office. All patient, hospital and surgeon identifiers on the completed SCF are removed before the form is sent to a first-line assessor for review. This assessor is selected from the same surgical specialty, but a different LHD to the treating consultant surgeon.

iii. First-line assessment. The first-line assessor makes an assessment of the reported death from the information submitted on the de-identified SCF, then completes the assessment form and returns it to CHASM. For 90.8 per cent of cases, no further information is needed and the audit findings are coded and entered in a database. The notifying surgeon receives a confidential feedback letter from the CHASM committee on the outcome of the review.

iv. Second-line assessment. In 9.2 per cent of cases, where there is either insufficient detail or potential deficiencies of care have been identified, a case note review is requested. This comprises a full medical case note review. At this stage anonymity is no longer feasible. The notifying surgeon receives confidential and privileged feedback from the CHASM committee, based on the assessor’s comments. All SLA reports are de-identified and distributed to CHASM committee members for noting.

v. Other types of feedback. Each year the participating surgeon will receive an individual summary of data that he/she has submitted, compared against the average for the specialty and all surgeons in NSW. An annual report of de-identified aggregated data is submitted to the Minister for Health, the CEC, NSW Health and the NSW State Committee of the RACS.

vi. Appeal. If the surgeon is dissatisfied with the outcome of the SLA, a third assessment will be arranged by the chairman to further review the reported death and validate the second-line assessor’s comments.

A flow chart illustrating the CHASM audit process and the key players involved is shown opposite.


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No


1.3.3 Data management and analysis

CHASM manages its data in a Microsoft Access 2010 relational database developed by the Western Australia Safety and Quality of Surgical Care Project at Curtin University of Technology. It stores data on patients, consultant surgeons and hospitals, as well as data collected from the SCF, first- and second-line assessments. It also creates letters for communicating with surgeons, including “thank you”, feedback and reminder letters, as well as management reports and feedback reports to surgeons.

Categorical data collected from the SCF and assessments was populated into the database, using TeleForm7. Information on diagnoses, cause of death and operations were coded using Read codes8. Other descriptive information relating to clinical care was manually entered in the database. Any areas of consideration/concern or adverse events noted in the patient’s management were also coded using the SASM devised codes, which are similar in structure to the Read codes and the text description was manually entered in the database.

The data was analysed using the IBM SPSS Statistics Version 19. Descriptive statistics were used to report on frequencies, percentages, median age and inter-quartile range. Due to rounding, percentages do not always total to 100. Numbers in parentheses (n) in the text represent the number of cases, or the number actually analysed. These vary, as some surgeons did not complete all data fields. Some data has been omitted due to small numbers (n≤5), to preserve privacy and data confidentiality (NSW Injury Risk Management Research Centre 2004).

A chi-square test was used to compare differences between independent proportions. The comparisons were two-sided and were considered statistically significant at p values less than 0.05. The kappa statistic was used for interrater reliability analysis to determine consistency between the surgeon’s self-assessment and the peer assessment of the surgical management of the patient. Its interpretation is as follows (Viera & Garrett, 2005):

Kappa Agreement

0 Less than chance agreement

0.01 – 0.20 Slight agreement

0.21 – 0.40 Fair agreement

0.41 – 0.60 Moderate agreement

0.61 – 0.80 Substantial agreement

0.81 – 0.99 Almost perfect agreement

Due to the time lag in reporting deaths and completing the assessment, some deaths recorded by CHASM during the reporting period either completed the audit process after 31 December 2010, or are proceeding through the audit process. They will be included in the next report.

7 TeleForm is a forms processing application, which can read, evaluate, verify and export handwritten information and tick box responses to end databases when a completed form is scanned (Cardiff Software Incorporated 2002).

8 The Read Codes are a comprehensive coded clinical language for over 98 000 medical conditions and interventions. They include terms relating to observations (signs and symptoms), diagnosis, procedures and investigations which map to other coding systems, including the International Classification of Diseases Ninth Revision (ICD-9) and the Classification of Surgical Operations & Procedures Fourth Revision (OPCS-4) (EPIC).


2. Audit participation

KEY POINTS

• By the end of 2010:

– 798 surgeons in NSW were participating in CHASM

– All eight former AHS were reporting hospital deaths, in which a surgeon was involved in the care, to CHASM.

2.1 Surgeon participationWhen CHASM receives a notification of death where a surgeon was involved, a surgical case form is sent to the consultant for completion, unless he/she is a non-participant (i.e., has advised verbally, or by writing, that they do not wish to participate). Surgeon participation in CHASM is, therefore, based on the return of a signed participation form and/or the return of a completed surgical case form.

By the end of December 2010, 798 of 1483 (53.8%) active fellows in NSW were participating in CHASM, with 325 and 241 also agreed to be first- and second-line assessors, respectively. This participation rate has exceeded the target of 50 per cent set in the last report. Table 1 shows the improvement in the number and rate of surgeon participation in CHASM between the last and current reporting periods.

Table 1: Change in surgeon participation in CHASM between the last and current report periods

Last reporting period This reporting period Change

Participating surgeons 563 (39.8%) 798 (53.8%) 235(14%*)

First-line assessors 261 325 64

Second-line assessors 185 241 56

* P<0.001

All participating surgeons and assessors receive one credit point for each hour spent on the audit. The points contribute to the RACS recertification (Category 3: Clinical Governance and Evaluation of Patient Care). In 2010, participation in a surgical mortality audit was mandated by the RACS, as a necessary component of recertification through the Continuing Professional Development Program.


2.1.1 By surgical specialty

Surgeons from general surgery, orthopaedics, urology, neurosurgery and vascular surgery accounted for most of the participants (n = 648, 81.2%) in CHASM. The following figures show the number of participants by surgical specialty and the proportion of active RACS fellows in NSW participating in CHASM.

Figure 3: Number of surgeons participating in CHASM by surgical specialty at 31 December 20109

0 100 200 300 400 500 600 700 800

Total

Other

Vascular

Urology

Plastic

Paediatric

Otolaryngology

Orthopaedic

Oral/Maxillofacial

Ophthalmology

Neurosurgery

Gynaecology

General

Cardiothoracic

Number of surgeons

Surg

ical

sp

ecia

lty*

34

322

11

42

161

37

31

77

46

798

17

1

13

6

* This list of surgical specialty is based on surgeons’ self-reported data.

Figure 4: Proportion of active RACS fellows participating in CHASM in NSW by surgical specialties at 31 December 2010

Total

Vascular

Urology

Plastic

Paediatric

Otolaryngology

Orthopaedic

Ophthalmology

Neurosurgery

General

Cardiothoracic

Active fellows participating in CHASM in NSW (%)

Surg

ical

sp

ecia

lty*

0 20 40 60 80 100

71

65

62

16

45

29

45

33

69

96

54

* This list of surgical specialty is based on that used in the RACS Activities Report for the period 1 January – 31 December 2010.

9 The denominators for calculation of percentages are based on figures reported in the RACS Activities Report for the period 1 January – 31 December 2010 (Royal Australasian College of Surgeons, 2011). Accessed: 27/04/2011 http://www.surgeons.org/media/416890/rpt2010_jan_to_dec_eoy_ar.pdf

http://www.surgeons.org/media/416890/rpt2010_jan_to_dec_eoy_ar.pdf


2.1.2 By health service (AHS)

For this reporting period, all public hospitals were under the jurisdiction of former area health services (AHS). The number of participating consultants in each former AHS refers to the number of surgeons who have at least one death recorded by CHASM and who have returned a signed participation letter and/or completed a surgical case form. The total number is less than that of the total number of participating surgeons by specialty, as stated in section 2.1.1, because it does not include those who have signed a participation letter, but who did not have a death recorded by CHASM.

At 31 December 2010, there were 667 participating consultants across the eight former AHS. Thirty-five of them were practising in more than one AHS. The following table shows the number and proportion of surgeons participating in CHASM by former AHS.

Table 2: Number and proportion10 of surgeons participating in CHASM by former area health service at 31 December 2010

Former area health serviceNumber (%) of surgeons participating in CHASM

Greater Southern 36 (35.3)

Greater Western 30 (50.0)

Hunter New England 110 (59.5)

North Coast 60 (60.6)

Northern Sydney Central Coast 101 (63.5)

South Eastern Sydney Illawarra 122 (36.3)

Sydney South West 140 (50.2)

Sydney West 103 (52.6)

10 The denominators for calculation of percentages are the total number of surgeons employed by the former AHS at 31 December 2010, as advised by the respective clinical audit managers or equivalent staff.


3. Audit progress

KEY POINTS

• Between 1 July 2009 and 31 December 2010, CHASM:

– Recorded the deaths of 3351 patient who were under the care of a surgeon

– Received surgical case forms (SCF) for 2278 deaths

– Completed the audit of 1812 deaths.

From 1 July 2009 to 31 December 2010, CHASM recorded 3351 deaths, in which the patient was under the care of a surgeon in a hospital. In the same period, there were approximately 580000 hospitalisations by 11 surgical service-related groups11 in NSW. The following figure presents a summary of the data on the CHASM audit process for this reporting period.

Figure 5: Summary of the CHASM audit process from 1 July 2009 to 31 December 2010

1812 audited deaths

Assessment from previous reporting period,completed & returned4

250

SCF completed & returned 1917 (57.2%)

SCF in progress 208 (6.2%)

No response3 1124 (33.5%)

Non-participant3 102 (3.1%)

SCF from previous reporting period,completed & returned4

361

2278 deaths with completed SCF

Terminal care568 (25.0%)

Audit process complete1 1562 (68.8%)

Awaiting Assessment2 148 (6.5%)

3351 deaths recorded

Note: percentages do not add to 100, due to rounding.

(1) The audit process is complete once the reported death has been assessed by first- +/– second-line assessor(s).

(2) Cases awaiting first- or second-line assessment. The time taken to have the case notes available for assessment can delay the assessment process considerably.

(3) “No response” refers to cases in which the surgeon has not returned a completed SCF after three reminder letters. “Non-participants” refers to cases in which the surgeons have indicated that they do not wish to participate in CHASM. There were 306 surgeons who did not respond to or participate in CHASM during the reporting period.

(4) SCF/first- or second-line assessments that were sent/requested in the previous reporting period and returned in this reporting period.

11 Cardiothoracic surgery, colorectal surgery, upper GIT surgery, neurosurgery, ENT & head and neck, orthopaedics, ophthalmology, plastic and reconstructive surgery, urology, vascular surgery and non-sub-specialty surgery. Data reported in Health Statistics NSW – Admitted Patient Report 2012. Accessed: 3/7/2012 http://www.health.nsw.gov.au/pubs/2012/pdf/admitted_patient_report_02.pdf

http://www.health.nsw.gov.au/pubs/2012/pdf/admitted_patient_report_02.pdf


3.1 By surgical specialty

The following tables show the rate of surgical case forms (SCF), first-line assessments (FLA) and second-line assessments (SLA) and the time taken to return, by surgical specialty between 1 July 2009 and 31 December 2010. Some data has been omitted, due to small numbers (n ≤ 5), to preserve privacy and data confidentiality.

Table 3: Percentage of SCFs, FLAs and SLAs completed and returned, of deaths recorded between 1 July 2009 and 31 December 2010, by surgical specialty

Surgical specialties

SCF returned FLA returned SLA returned

n (%) n (%) n (%)

Anaesthetics *

Cardiothoracic 149 (58.9) 111 (96.5) 20 (87.0)

General Surgery 852 (58.6) 539 (97.6) 54 (84.4)

Gynaecology *

Neurosurgery 324 (62.1) 337 (99.7) 10 (100)

Ophthalmology * *

Orthopaedics 254 (42.9) 231 (97.9) 16 (100)

Otolaryngology 16 (72.7) 12 (100)

Paediatrics 11 (91.7) 8 (100) *

Plastic 20 (62.5) 13 (92.9) *

Urology 80 (69.6) 38 (95.0) 12 (92.3)

Vascular Surgery 231 (72.0) 164 (96.5) 17 (89.5)

All 1940** (58.3**) 1453*** (97.8***) 135*** (88.8***)

* This data is omitted due to small numbers (n ≤ 5).

** Total number and proportion of SCF returned for 1917 recorded deaths. Some deaths involved the care of more than one surgeon and had more than one SCF returned.

*** Total number and proportion of FLA and SLA returned for 1562 recorded deaths that had completed the audit process. Some deaths had more than one first- or second-line assessment, due to multiple specialty involvement in care.


Table 4: Time taken to return SCFs, FLAs and SLAs of deaths recorded between 1 July 2009 and 31 December 2010 by surgical specialty

Surgical specialty SCF returned FLA returned SLA returned

Median (quartiles) days



Cardiothoracic 20 (9 - 52) 10 (8 - 21) 24 (9 - 48)

General Surgery 27 (14 - 64) 15 (9 - 27) 28 (14 - 49)

Gynaecology *

Neurosurgery 27 (10 - 81) 8 (0 - 16) 17 (12 - 36)

Ophthalmology * * *

Orthopaedics 31 (18 - 64) 13 (9 - 22) 28 (12 - 44)

Otolaryngology 24 (16 - 33) 14 (9 - 26)

Paediatrics 71 (27 - 96) 17 (13 - 21)

Plastic 43 (12 - 75) 12 (7 - 15) *

Urology 21 (13 - 51) 25 (11 - 39) 19 (14 - 29)

Vascular Surgery 22 (9 - 56) 13 (9 - 23) 29 (20 - 90)

All 26 (13 - 64) 13 (8 - 22) 27 (13 - 46)* This data is omitted due to small numbers (n ≤ 5).

• Paediatric surgeons had the highest return rate of SCF (91.7%), but the longest median days (71) to return them.

• Orthopaedic surgeons had the lowest return rate of SCF (43.1%) and above average median days (31) to return the forms.

• All surgical specialties had a return rate of over 90 per cent for FLA, with otolaryngology and paediatrics at 100 per cent.

• Urology had the longest median of 25 days to return a FLA. Neurosurgery had the shortest median of 8 days.

• The return rate of SLA is over 85 per cent for nearly all specialties, with neurosurgery and orthopaedics at 100 per cent.

• Neurosurgery and urology had the shortest median of 17 and 19 days respectively to return a SLA.


3.2 By former area health service

The following figure and table show the return rate of surgical case forms (SCF) and the time taken, by former area health services during the reporting period. Due to small numbers of recorded deaths for The Children’s Hospital at Westmead (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Figure 6: Response to surgical case forms sent for 3351 recorded deaths between 1 July 2009 and 31 December 2010, by former area health service

0%

20%

40%

60%

80%

100%

Non-participantNo responseSCF not yet returnedSCF completed and returned

AllSydney West

Sydney South West

South Eastern Sydney Illawarra

Northern Sydney Central Coast

NorthCoast

Hunter New

England

GreaterWestern

GreaterSouthern

Children’s Hospital at Westmead*

Area health service

Perc

enta

ge

of

reco

rded

dea

ths

51 37 72 80 52 63 54 68 62

32

47 1713 40 30 37 25 30


• The return rates of SCF at North Coast (79.6%), Hunter New England (71.9%) and Sydney West (68.3%) area health services are higher than the State rate (61.7%).

• No response and non-participation rates were highest in the Greater Western area health service (51.9%), followed by Greater Southern (44.6%) and Northern Sydney Central Coast (43.5%).


Table 5: Time taken to return surgical case forms, of deaths recorded between 1 July 2009 and 31 December 2010 (n=1940), by former area health service

Former area health service Median (quartiles) days

Greater Southern 22 (13 - 32)

Greater Western 43 (17 - 107)

Hunter New England 23 (14 - 58)

North Coast 26 (11 - 59)

Northern Sydney Central Coast 27 (12 - 61)

South Eastern Sydney Illawarra 29 (11 - 82)

Sydney South West 22 (11 - 52)

Sydney West 29 (14 - 69)

NSW 26 (13 - 64)

• Greater Southern and Sydney South West area health services had the shortest median days of 22, for returning surgical case forms and Greater Western had the longest of 43 days.

• The time taken to return a surgical case form can be affected by many factors, including direct report of deaths to CHASM by surgeons, access to the patient medical records and support from clinical audit managers at area health services.


3.3 Discussion

There has been significant improvement in the engagement of surgeons and efficiency of the audit process. Our data indicates the following changes in the audit outputs since the last reporting period.

Table 6: Change in audit outputs between the last and current reporting periods

Last reporting period Jan 2008 – Jun 2009

This reporting period Jul 2009 – Dec 201012 Difference

Number of surgical case forms (SCF) returned

1251 2304 1053

Median days to return an SCF 29 31 2

Number of first-line assessments (FLA) completed

896 1811 557

Median days to return an FLA 19 13 6*

Number of second-line assessments (SLA) completed

74 225 61

Median days to return an SLA 25 27 2*

*Statistically significant (p<0.01).

A number of factors have contributed to these improvements, including:

• Better staffing of the project team to record notifications, collect and enter/code data and process cases for auditing.

• Chair’s regular weekly visits to advise project team on cases for auditing and issues relating to the efficiency of the audit process and quality of the audit data.

• Availability of a clinical expert to review and advise on general surgical deaths.

• Designated staff at former area health services providing notification to CHASM weekly, fortnightly or monthly.

• A five-working-day rule for mailing SCFs to surgeons when a notification is received, to help them recall the case and complete the form.

• A three-reminder-letter procedure to improve return of SCF, FLA and SLA.

• Mandatory participation in ANZASM (CHASM in NSW) to meet the Continuing Professional Development (CPD) requirements of the RACS.

The increase in the number of median days to return a SLA could be due to complexity and large volumes of the case notes for reviewing. Some second-line assessors had misplaced or lost the assessment pack, which required re-sending and resulted in prolonged assessment time. The project team has sourced a brightly coloured satchel to hold the case notes and assessment documents, so that they can be easily identified in a busy surgeon’s office. The team will continue to monitor this performance data.

12 The data in this column includes some SCF, FLA and SLA of deaths that were recorded in the previous reporting period, but returned in this reporting period.

Part A

Surgical Specialty Figures


4. Surgical specialty findings

KEY POINTS

• The median age of the patients of 1812 audited deaths was 77 years (range <1 month – 104 years)

• There were 975 (53.8%) males and 837 (46.2%) females.

• Most of the audited deaths:– had an emergency admission (n=1504, 83.0%)– had an ASA grade of 3 or 4 (n=1300, 71.7%)– were at considerable or expected risk of death (n=1072, 59.2%).

• The most common co-morbid factors increasing the risk of death were cardiovascular, age and respiratory conditions.

• Most of the audited deaths (n=1601, 88.4%) had at least one operation.

• A total of 2193 operations were recorded for the audited deaths.

• In 1945 (88.7%) operations, consultant surgeons made the decision to operate and performed 1308 (59.6%) of them.

• Venous thromboembolic prophylaxis was used in 1473 (81.3%) audited deaths.

• Pre-operative delays or errors in confirmation of main surgical diagnosis was reported in 165 (9.1%) audited deaths.

• A definable post-operative complication was reported in 573 (31.6%) audited deaths.

• CHASM assessors identified 386 potentially preventable deficiencies of care in 262 (14.5%) audited deaths.


4.1 Demographics

4.1.1 Age and sex distribution

There were 975 (53.8%) males and 837 (46.2%) females among the 1812 audited deaths. They were mostly elderly, with a median age of 77 years (range <1 month - 104 years). The following table shows the distribution of the audited deaths by age groups and sex.

Table 7: Age and sex distribution of audited deaths (n=1812)

Age Groups (Years)Male Female Total

n % n % n %

Total 975 53.8 837 46.2 1812 100

0 - 34 36 70.6 15 29.4 51 100

35 - 64 218 61.9 134 38.1 352 100

65 - 79 362 58.8 254 41.2 616 100

80+ 359 45.3 434 54.7 793 100

Median (interquartile range) age

75 (63-83) 80 (69-86) 77 (66-85)

• 1409 (77.8%) audited deaths were of patients aged 65 years and over.

• Male deaths predominate in the age groups below 80 years.

4.2 AdmissionsAdmission data was recorded in 1778 (98.1%) audited deaths, with 274 (15.1%) reported as elective (planned) and 1504 (83.0%) as emergency admissions. The following table and figure show the admission status of audited deaths, by age group and surgical specialty, respectively. Due to the small number of admissions for the specialty of ophthalmology (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Table 8: Age and admission status of audited deaths

Age group

Admission StatusTotal

Elective Emergency

n % n % n %

0-34 1 0.4 50 3.3 53 2.9

35-64 77 28.1 297 19.8 379 20.9

65-79 116 42.3 506 33.6 636 35.1

80+ 80 29.2 651 43.3 744 41.1

Total 274 15.1 1504 83.0 1812 100.0

Note: Missing admission data in 34 audited deaths.

The proportion of audited deaths with:

• an elective admission was highest in the age group between 65 and 79 years (n=116, 42.3%).

• an emergency admission increases with age and was highest in 80 years and over (n=692, 46.0%).


Figure 7: Admission types of audited deaths by surgical specialty (n=1812)

Audited deaths (%)

Surg

ical

sp

ecia

lty*

0 20 40 60 80 100

All

Vascular

Urology

Plastic

Paediatric

Otolaryngology

Orthopaedics

Ophthalmology*

Neurosurgery

General

Cardiothoracic

Elective Emergency Not reported

23

16

7

33

13

33

34

20

15

6

74

83

90

67

88

60

60

78

83

92

3

1

2

7

6

2

2

2

* This data is omitted due to small numbers (n ≤ 5). Note: percentages do not always add to 100, due to rounding.

The majority of audited deaths (n=1504, 83.0%) were of patients who had an emergency admission, especially in the specialties of neurosurgery, orthopaedics and paediatric.


4.2.1 Confirmed surgical diagnoses

The following table lists the three most reported confirmed surgical diagnoses of the 1812 audited patient deaths, by surgical specialty.

Table 9: The three most reported confirmed surgical diagnoses of 1812 audited patient deaths by surgical specialty

Surgical specialty

Three most reported confirmed admission diagnoses in Read code description

First Second Third

CardiothoracicCoronary artery

diseaseAortic stenosis Dissecting aortic aneurysm

General Intestinal

obstructionIschaemic

bowelMalignant neoplasm

of colon

NeurosurgerySubdural

haematoma Subarachnoid haemorrhage

Intracerebral haemorrhage

Ophthalmology * * *

OrthopaedicsFracture of

proximal femurOther fracture

of femur*

Otolaryngology * * *

Paediatrics * * *

Plastic * * *

UrologyMalignant neoplasm of urinary bladder

* *

VascularRuptured abdominal

aortic aneurysmPeripheral

vascular diseaseAbdominal aortic aneurysm

without rupture



4.3 Transfers

Surgeons reported pre-operative transfer for tertiary care and/or facility in 474 (26.2%) audited deaths. The following summarises the data on pre-operative transfer.

• In 327 (69.0%) transfers, the distance was recorded, with a median of 30km and a range from 1 to 2000km.

• Delay and/or had problems was reported in 61 (12.9%) transfers.

• Nearly all transfers (n=418, 88.2%) were reported as appropriate.

• The level of care during transportation was also reported as appropriate in nearly all the transfers (n=433, 91.4%).

• Sufficient clinical information was reported in almost all of the transfers (n=417, 88.0%).

The following figure shows the distribution of pre-operative transfer of patient of the audited deaths, by surgical specialty. Due to the small amount of transfer data for the specialties of otolaryngology, paediatrics and ophthalmology (n ≤ 5), this is omitted, to preserve privacy and data confidentiality.

Figure 8: Pre-operative transfer of audited deaths by surgical specialty (n=1812)

Audited deaths (%)

Surg

ical

sp

ecia

lty

Transfer - Yes Transfer - No

0 20 40 60 80 100

All

Vascular

Urology

Plastic

Paediatric*

Otolaryngology*

Orthopaedics

Ophthalmology*

Neurosurgery

General

Cardiothoracic

*This data is omitted due to small numbers (n ≤ 5).

• The proportion of audited deaths with a pre-operative transfer is higher in the specialties of neurosurgery (45%), cardiothoracic surgery (40%) and plastic surgery (40%).


4.4 Assessment

4.4.1 American Society of Anaesthesiologists (ASA) grades

Surgeons were asked to indicate the patient’s physical status using the American Society of Anaesthesiologists (ASA) grades13, which are an internationally recognised classification to assess fitness for anaesthesia and surgery. Table 6 describes the six ASA grades.

Table 10: ASA grades

ASA Grade Characteristics

1 A normal healthy patient

2 A patient with mild systemic disease and no functional limitation

3 A patient with moderate systemic disease and definite functional limitation

4 A patient with severe systemic disease that is a constant threat to life

5 A moribund patient unlikely to survive 24 hours, with or without an operation

6 A brain-dead patient for organ donation

ASA grades were reported in 1740 (96.0%) audited patient deaths. The following figure shows the ASA grades of audited deaths, by surgical specialties. Due to the small numbers in the data on ASA grades for ophthalmology (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Figure 9: Distribution of audited deaths by ASA grade and surgical specialty (n=1812)

Audited deaths (%)

Surg

ical

sp

ecia

lty

0 10020 40 60 80

ASA 4ASA 3ASA 2ASA 1

All

Vascular

Urology

Plastic

Paediatric

Otolaryngology

Orthopaedics

Ophthalmology*

Neurosurgery

General

Cardiothoracic

ASA 5

ASA 6Not reported

24

33

45

50

13

60

45

29

32

17

54

40

36

33

63

33

27

53

40

30


13 “ASA Physical Status Classification System”. American Society of Anesthesiologists. http://www.asahq.org/clinical/physicalstatus.htm. Retrieved 10 February 2010.

http://www.asahq.org/clinical/physicalstatus.htm


• The majority of the audited deaths (n=1300, 71.7%) were of patients who had an ASA grade of either 3 or 4, meaning that they were assessed to have either a moderate or severe systemic disease prior to treatment.

• Paediatric (n=7, 87.5%) and neurological (n=150, 53%) deaths were predominately of patients who had a severe life-threatening systemic disease or who were unlikely to survive 24 hours.

• Twenty-five (8.8%) neurological deaths were of patients who were previously normal and healthy.

4.4.2 Malignancy

Surgeons reported the presence of malignancy in 469 (25.9%) of audited deaths. The malignancy contributed to 307 (65.5%) of these deaths.

4.4.3 Co-morbid factors

Surgeons reported significant co-morbid factors that increased the risk of death in 1619 (89.3%) audited deaths. The median number of co-morbid factors in these deaths was two. Table 11 shows the proportions of audited deaths by types of co-morbid factors and surgical specialty, during the reporting period. Due to small numbers of audited deaths with co-morbid factors for the specialty of ophthalmology (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Table 11: Types of co-morbid factors in audited deaths by surgical specialty (n=1619)

Surgical specialty Cardiovascular Age Respiratory Renal

Cardiothoracic 70.7 35.7 40.7 20.0

General Surgery 65.7 53.8 41.9 28.7

Neurosurgery 51.0 28.7 24.8 8.4

Ophthalmology*

Orthopaedics 80.8 66.9 47.7 33.4

Otolaryngology 27.3 54.5 36.4 9.1

Paediatrics 42.9 42.9 42.9 14.3

Plastic 90.9 63.6 36.4 27.3

Urology 71.9 50.9 31.6 36.8

Vascular Surgery 88.1 50.3 45.6 44.0

All 69.6 51.0 40.7 28.2


Surgical specialtyNeurological/

psychiatricDiabetes

Advanced malignancy

Obesity Hepatic

Cardiothoracic 6.4 15.0 9.3 7.1 3.6

General Surgery 18.8 16.5 14.3 11.4 9.5

Neurosurgery 18.8 14.4 8.9 9.9 5.0

Ophthalmology*

Orthopaedics 22.6 13.9 9.4 5.6 5.6

Otolaryngology 27.3 9.1 54.5 9.1 0

Paediatrics 0 0 0 0 0

Plastic 9.1 27.3 0 9.1 9.1

Urology 15.8 14.0 29.8 14.0 1.8

Vascular Surgery 15.0 26.9 3.6 12.4 5.2

All 17.7 16.8 11.7 10.0 6.9


• Among the audited deaths with co-morbid factors (n=1619), the most common factors increasing the risk of death were cardiovascular (n=1127, 69.6%), age (n=826, 51.0%) and respiratory (n=659, 40.7%).

• The proportion of audited deaths with:

– cardiovascular co-morbid factors was higher in the plastic surgery, vascular and orthopaedic specialties

– respiratory co-morbid factors was higher in the specialty of orthopaedics

– renal co-morbid factors was higher in vascular, urology and orthopaedic specialties

– neurological/psychiatric co-morbid factors was higher in otolaryngology

– advanced malignancy co-morbid factors was higher in the specialties of otolaryngology and urology

– diabetes as a reported co-morbid factor was higher in the vascular and plastic specialties

– age as a reported co-morbid factor was higher in the orthopaedic and plastic specialties.

In 193 (10.7%) of the audited deaths, the surgeons did not report any significant co-morbid factors that increased the risk of death. These deaths had the following characteristics:

• Males represented 59.6% (n=115).

• Most (n=159, 82.4%) had an emergency admission.

• They were mainly admitted to the specialties of neurosurgery (n=81, 42%) and general surgery (n=65, 33.7%).

• They were younger, with a median age of 59 years.

• Just over half had an ASA grade of 3, 4 or 5 (n=98, 50.8%), but 44 (22.8%) had a grade of 1.

• Most (n=126, 65.3%) were assessed to be at considerable or expected risk of death.


4.4.4 Risk of death before surgery

Prior to surgery, surgeons consider the risk of death of the patient, to determine if surgery would be beneficial. Figures 10 and 11 show the perceived risk of death before surgery of the audited deaths, by surgical specialty and operative status. Due to the small number of audited deaths with reported risk of death before surgery for the specialty of ophthalmology (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Figure 10: Surgeons’ perceived risk of death before surgery of audited deaths, by surgical specialty (n=1812)

Audited deaths (%)

Surg

ical

sp

ecia

lty

ConsiderableSmall ModerateMinimal Expected Not reported

13 928 43

0 20 40 60 80 100

All

Vascular

Urology

Plastic

Paediatric

Otolaryngology

Orthopaedics

Ophthalmology*

Neurosurgery

General

Cardiothoracic

9 1520 46

5 2621 45

10 426 52

8 2542 8

1325 50

13 1320 33

23 531 24

8 828 49

9 1423 46


• More than half of the audited deaths (n=1072, 59.2%) were reported to be at considerable or expected risk of death before surgery, particularly in the specialty of neurosurgery (n=201, 71.0%).

• A small number of audited deaths (n=43, 2.4%) were reported to be at minimal risk of death.

• Almost one-third of the urological deaths (n=20, 32.3%) were reported to have minimal to small risk of death before surgery.


Figure 11: Distribution of audited deaths by operative status and perceived risk of death before surgery (n=1812)

Audited deaths (%)

Perc

eive

d r

isk

of

dea

th b

efo

re s

urg

ery

Had operation No operation

0 20 40 60 80 100

Not reported

Expected

Considerable

Moderate

Small

Minimal93

92

91

82

59

15

95

7

8

9

18

41

5

• Eighty-two per cent, or 200 of audited deaths with an expected perceived risk of death before surgery, had an operation.

• Conversely, seven per cent, or three of audited deaths with minimal perceived risk of death before surgery did not have an operation.

One of the tasks for assessors is to rate the audited patient’s risk of death before surgery. The table below compares the perceived risk of death before surgery of audited deaths, between the participating surgeons and the assessors.

Table 12: Comparison of perceived risk of death of audited deaths before surgery between participating surgeons and CHASM assessors

Surgeons’ view Assessors’ view

Minimal Small Moderate Considerable Expected

Minimal 14 11 12 2 0

Small 5 70 56 22 5

Moderate 2 34 208 138 16

Considerable 2 8 98 600 100

Expected 0 0 10 115 109

kappa = 0.403 (p<0.001), 95% CI (0.368, 0.438).

• Surgeons and assessors agreed on the perceived risk of death before surgery of 1001 (55.2%) audited deaths.

• The kappa score14 indicated fair agreement between participating surgeons and CHASM assessors on perceived risk of death before surgery.

14 The kappa statistic is a quantitative measure of the magnitude of agreement between raters beyond chance. Please refer to page 18 for its interpretation


4.5 Management

4.5.1 Operation

Surgeons reported the following operative status for the audited deaths:

• 1601 (88.4%) had at least one operation

• 211 (11.6%) did not have any operations

• 445 of the 1601 deaths (27.8%) returned to theatre for a second or subsequent operation.

The following figures show the operative status of audited deaths by surgical specialty and admission status. Due to the small number of audited deaths for the specialty of ophthalmology (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Figure 12: Distribution of audited deaths by operative status and surgical specialty (n=1812)

Audited deaths (%)

Surg

ical

sp

ecia

lty

Operation No operation

0 20 40 60 80 100

All

Vascular

Urology

Plastic

Paediatric

Otolaryngology

Orthopaedics

Ophthalmology*

Neurosurgery

General

Cardiothoracic 98

89

89

67

100

852

11

11

33

15

100

88

928

12

8

92


• An operation was reported in all the audited deaths of paediatric (n=8, 100%) and plastic surgery (n=15, 100%), and nearly all of cardiothoracic surgery (n=149, 98%).

• One-third (n=4, 33%) of the audited deaths of otolaryngology did not have any operations reported.


Figure 13: Distribution of audited deaths by admission and operative status (n=1812)

Not reported97

3

Audited deaths (%)

Ad

mis

sio

n s

tatu

s

0 20 40 60 80 100

Emergency86

14

Elective97

3

No operationOperation

• An operation was performed on nearly all audited deaths with an elective admission (n=267, 97.1%).

• For audited deaths with an emergency admission, 204 (13.6%) did not have an operation.

For the 211 (11.6%) audited deaths where no operation was performed:

• The consultant surgeon made the decision not to operate in 56 (26.5%) deaths.

• The patient refused operation in nine (4.3%) deaths.

• The decision was made by surgeons and/or patients to limit treatment in 30 (14.2%) deaths.

• Thirty-seven (17.5%) deaths were not a surgical problem.

• Thirteen (6.2%) deaths were rapid.

• CHASM assessors considered that seven (3.3%) of these deaths might have benefited from an operation.


A total of 2193 operations was recorded for the 1601 audited deaths of which the patient had at least one operation. The following table shows the three most reported operations (in Read code description) by surgical specialty. When two or more operations are equal in numbers for ranking, they are listed in the same cell to denote their equal rank.

Table 13: The three most reported operations (in Read code description) on 1601 audited deaths by surgical specialty

Surgical specialty

Three most reported operations in Read code description

First Second Third

CardiothoracicCoronary artery

bypassAortic valve replacement

Repair of mitral valve

GeneralOperations on small bowel

Freeing of adhesions

Sigmoid colectomy and exteriorisation of bowel

NeurosurgeryBurrhole(s) for ventricular

external drainageCraniotomy for evacuation

of haematomaCraniotomy for clipping

of aneurysm

Ophthalmology * * *

OrthopaedicsPrimary reduction and

internal fixation of proximal femoral fracture

Hemiarthroplasty of hip

Internal fixation of other fracture


Paediatrics * * *

PlasticDebridement of skin/

burnt skin* *

UrologyConstruction of

ileal conduitInsertion of

ureteric stentTherapeutic cystoscopy

VascularOperation on

aneurysm of aortaAmputation above/

below kneeEmbolectomy

of femoral artery

* This data is omitted due to small number (n ≤ 5).


For audited deaths with an operation, the following figure shows the timing of the operation by admission type. If the death had more than one operation reported, only the timing of the first operation is presented.

Figure 14: Distribution of audited deaths with an operation by admission type and timing of first operation (n=1573)15

Audited operative deaths (%)

Ad

mis

sio

n s

tatu

s

0 20 40 60 80 100

Elective

Emergency

All

Scheduled emergency (≥ 24 hours after admission)Emergency (< 24 hours)

Immediate (< 2 hours)Elective

95 2

8 3526 31

23 2922 26

• More than half of the emergency admissions (n=784, 61.3%) had an operation within 24 hours.

• The majority of elective admissions (n=250, 95.1%) had the operation as planned.

• A small proportion of elective admissions, had an immediate (n=3, 1.1%) or emergency (n=4, 1.5%) operation following their admissions due to unexpected complications.

15 This figure is the total number of audited deaths with reported data on timing of first operation.


4.5.2 Grade of surgeon

Surgeons were asked to indicate the grade of surgeon involved in the following processes, for a maximum of three operations performed:

• Made the decision to operate

• Performed the operation

• Assisted at the operation

• Was present in theatre.

The following table shows the proportion of audited deaths by grade of surgeon involved in the above processes for a maximum of three operations. “Other” was reported by some surgeons and it mostly refers to “fellow”.

Table 14: Grade of surgeon and their involvement in three operations performed on audited deaths

Grade of surgeon

ConsultantAdvanced surgical trainee

RegistrarBasic

surgical trainee

GP surgeon

Other

Operation 1 (n=1601)

Deciding (%) 89.1 1.7 1.2 0 0.1 0.4

Operating (%) 58.2 18.4 7.4 0.4 0.1 2.3

Assisting/ In theatre (%)

7.1 18.6 15.3 3.2 0.1 1.1

Operation 2 (n=445)

Deciding (%) 80.2 1.6 0 0 0 0.4

Operating (%) 59.8 14.6 3.8 0 0 2.9


4.3 18.9 9.7 1.1 0 0.9

Operation 3 (n=148)

Deciding (%) 82.4 0.7 0 0 0 0.7

Operating (%) 61.5 13.5 2.7 0 0 4.7


6.1 16.9 10.1 1.4 0 0.7


The involvement of consultant surgeons in the audited deaths is further examined by their presence in theatre, i.e., performed, assisted, or attended the operation. The following figure shows the proportion of audited deaths with a consultant surgeon present in theatre in at least one operation, by surgical specialty and admission type. Due to the small number of operative deaths for the specialties of ophthalmology, otolaryngology, paediatric and plastic surgery (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Figure 15: Proportion of audited operative deaths of which the consultant surgeon was in theatre for at least one operation by admission type and surgical specialty (n= 1601)16

Audited operative deaths with consultant surgeons in theatre (%)

Surg

ical

sp

ecia

lty

EmergencyElective

0 20 40 60 80 100

All

Vascular

Urology

Plastic*Paediatric*

Otolaryngology*

Orthopaedics

Ophthalmology*

Neurosurgery

General

Cardiothoracic8579

8376

8246

8653

9556

7279

8266

*This data is omitted due to small number (n ≤ 5).

• More than half the neurosurgical audited deaths where the patient had an emergency admission (n=124, 53.7%), did not have the consultant surgeon in theatre during the operation.

Surgeons reported the presence of an anaesthetist at 2023 (92.2%) of the operations performed. They also reported that 111 (5.1%) operations were abandoned upon finding a terminal condition.

16 The total number of audited deaths where the patient had at least one operation.


4.5.3 Use of high-dependency and intensive care units

Surgeons reported the use of intensive care unit (ICU) or high-dependency unit (HDU) pre-operatively and/or post-operatively in 1232 (68.0%) audited deaths as follows:

• pre-operatively in 779 (43.0%) deaths

• post-operatively in 804 (44.4%) deaths

• pre-operatively and post-operatively in 405 (22.6%) deaths.

The following figure shows the proportion of audited deaths with reported use of ICU or HDU by surgical specialty. Due to the small numbers of audited deaths for the specialty of ophthalmology (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Figure 16: Proportion of audited deaths with reported use of intensive care unit or high-dependency care unit, by surgical specialty (n=1812)

Audited deaths (%)

Surg

ical

sp

ecia

lty

No - ICU/HDUYes - ICU/HDU

0 20 40 60 80 100

All

Vascular Surgery

Urology

Plastic

Paediatrics

Otolaryngology

Orthopaedics

Ophthalmology*

Neurosurgery

General Surgery

Cardiothoracic 8119

7030

919

4258

6040

5941

6832

6733

8813

6040

* This data is omitted due to small number (n ≤ 5).

The reported use of ICU or HDU in audited deaths was:

• Highest among neurosurgery (n=257, 90.8%), following by paediatrics (n=7, 87.5%) and cardiothoracic surgery (n=123, 80.9%)

• Lowest among orthopaedics (n=125, 42.1%).


The following table shows the distribution of audited deaths with reported use of ICU or HDU, by perceived risk of death before surgery and by operative status.

Table 15: Reported use of intensive care unit or high-dependency unit in audited deaths, by surgeons’ perceived risk of death before surgery and operative status (n=1812)

Use of ICU or HDU

Yes No

Perceived risk n % n %

Minimal 13 30 30 70

Small 101 61 64 39

Moderate 268 64 150 36

Considerable 605 73 223 27

Expected 181 74 63 26

Not reported 64 56 50 44

Operative status

Had operation 1148 72 452 28

No operation 84 40 128 60

All 1232 68 580 32

The reported use of ICU or HDU in audited deaths:

• increases with increased perceived risk of death

• is higher among those with an operation.

Among the 580 audited deaths which did not have reported use of ICU or HDU, CHASM assessors considered that 42 (7.2%) would have benefited from ICU or HDU care.


4.5.4 Venous thromboembolism (VTE) prophylaxis

Surgeons reported the use of prophylaxis against venous thromboembolism (VTE) in 1473 (81.3%) audited deaths. The following figure shows the use of VTE prophylaxis in audited deaths by surgical specialty. Due to the small numbers of audited deaths for the specialty of ophthalmology (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Figure 17: Distribution of audited deaths, by use of VTE prophylaxis and surgical specialty (n=1812)

Audited deaths (%)

Surg

ical

sp

ecia

lty

VTE prophylaxis - NoVTE prophylaxis - Yes

00 2020 4040 6060 8080 100100

All

Vascular

Urology

Plastic

Paediatric

Otolaryngology

Orthopaedics

Ophthalmology*

Neurosurgery

General

Cardiothoracic

90

86

81

80

50

80

76

75

81

10

14

19

20

50

100

20

24

25

19


• Use of VTE prophylaxis was highest in orthopaedic audited deaths (n=266, 89.6%).

• VTE prophylaxis was not used in any of the paediatric audited deaths.

Surgeons reported that one or more of the following VTE prophylaxis was used:

• Heparin (n=1061, 72.0%)

• Thromboembolic deterrent (TED) stockings (n=836, 56.8%)

• Compression (n=664, 45.1%)

• Aspirin (n= 70, 4.8%)

• Warfarin (n=48, 3.3%)

• Other17 (n=28, 1.9%).

17 Included clopidogrel/plavix.


The use of VTE prophylaxis was not reported in 339 (18.7%) audited deaths. Surgeons gave the following reasons for not using VTE prophylaxis in 196 (57.8%) of these deaths:

• It was not appropriate (n=152, 77.6%)

• It was an active decision to withhold (n=39, 19.9%)

• It was an omission/error (n=5, 2.6%).

CHASM assessors considered that the decision made by the surgeon on the use or non-use of VTE prophylaxis was appropriate in 1515 (83.6%) audited deaths – of which 241 (15.9%) did not have any reported VTE prophylaxis.

4.6 Clinical incidents

4.6.1 Pre-operative delay or errors

Surgeons reported pre-operative delay or errors in confirmation of main surgical diagnosis in 165 (9.1%) audited deaths. The delay or errors were associated with:

• Medical unit (n=53, 32.1%)

• Surgical unit (n=40, 24.2%)

• General practitioner (n=19, 11.5%)

• Other areas (n=59, 35.8%) such as various other hospital departments.

Surgeons also reported the delay or errors were due to:

• Unavoidable factors (n=37, 22.4%)

• Misinterpretation of results (n=27, 16.4%)

• Failure to do correct test (n=25, 15.2%)

• Inexperience of staff (n=20, 12.1%)

• Results not seen (n=7, 4.2%)

• Various other factors (n=58, 35.2%).

4.6.2 Post-operative complications

Surgeons reported a definable post-operative complication in 573 (31.6%) audited deaths. They were described as follows:

• Significant post-operative bleeding (n=77, 13.4%)

• Procedure related sepsis (n=65, 11.3%)

• Tissue ischaemia (n=64, 11.2%)

• Anastomotic leak (n=52, 9.1%) from mostly colorectal and small bowel

• Vascular graft occlusion (n=17, 3.0%)

• Endoscopic perforation (n=7, 1.2%)

• Various other complications (n=321, 56.0%).

In addition, surgeons reported that there was a delay in recognising post-operative complications in 37 (6.5%) audited deaths.


The following figure shows the distribution of audited deaths with post-operative complications, by surgical specialty and admission type. Due to the small numbers for the specialties of ophthalmology, otolaryngology, paediatric and plastic surgery (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Figure 18: Proportion of audited deaths with post-operative complications by surgical specialty and admission type (n=1567)18

EmergencyElective

Audited operative deaths with post-operative complications (%)

Surg

ical

sp

ecia

lty

0 20 40 60 80 100

All

Vascular Surgery

Urology

Plastic*

Paediatrics*

Otolaryngology*

Orthopaedics

Ophthalmology*

Neurosurgery

General Surgery

Cardiothoracic 7150

6836

4719

5019

5213

5638

6131

*This data is omitted due to small numbers (n≤5).

• The proportion of audited deaths with post-operative complications was higher among those admitted electively than those admitted as an emergency.

18 The total number of audited deaths in which the patient had an operation and whose admission data was reported by the surgeon.


4.6.3 Unplanned return to theatre

Surgeons reported an unplanned return to theatre in 250 (15.6%) audited deaths. The following figure shows their distribution by surgical specialty and admission type. Due to the small numbers for the specialties of ophthalmology, otolaryngology, paediatric and plastic surgery (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Figure 19: Distribution of audited operative deaths with an unplanned return to theatre, by admission type and surgical specialty (n=1567)19

EmergencyElective

Audited operative deaths with an unplanned return to theatre (%)

Surg

ical

sp

ecia

lty

0 20 40 60 80 100

All

Vascular Surgery

Urology

Plastic*

Paediatrics*

Otolaryngology*

Orthopaedics

Ophthalmology*

Neurosurgery

General Surgery

Cardiothoracic 2919

2617

2413

96

296

2817

2514


• The proportion of audited deaths with unplanned return to theatre was higher among those who had

an elective admission (n=66, 24.7%), than those who had emergency admissions (n=182, 14.0%).

19 The total number of audited deaths of which the patient had an operation and whose admission data was reported by the surgeon.


4.6.4 Unplanned admission to ICUSurgeons reported an unplanned admission to ICU in 321 (17.7%) audited deaths. The following figure shows their distribution by surgical specialty and admission type. Due to the small numbers on unplanned admission to ICU for the specialties of ophthalmology, otolaryngology, paediatric and plastic surgery (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Figure 20: Distribution of audited deaths with an unplanned admission to ICU, by admission type and surgical specialty (n=1778)20

EmergencyElective

Audited operative deaths with an unplanned ICU admission (%)

Surg

ical

sp

ecia

lty

0 20 40 60 80 100

All

Vascular Surgery

Urology

Plastic*

Paediatrics*

Otolaryngology*

Orthopaedics

Ophthalmology*

Neurosurgery

General Surgery

Cardiothoracic 26

3314

28

5518

4814

2421

3315

13

13


• The proportion of audited deaths with an unplanned admission to ICU was higher among those who had an elective admission (n=90, 32.8%), than those who had an emergency admission (n=223, 14.8%).

4.6.5 Unplanned re-admission within 30 days of surgery

Surgeons reported an unplanned re-admission within 30 days of surgery in 65 (3.6%) audited deaths. These represented:

• 6.0% of all audited deaths with an elective admission

• 3.6% of all audited deaths with an emergency admission.

20 This figure is the total number of audited deaths with admission data reported by surgeons.


4.6.6 Hospital infection

Surgeons reported acquired hospital infection in 409 (22.6%) audited deaths. Over three-quarters were from general surgery (n=188, 45.9%), orthopaedics (n=76, 18.6%), neurosurgery (n=42, 10.3%) and vascular surgery (n=42, 10.3%) specialties.

Their infections were reported as follows:

• Acquired before transfer (n=9221, 22.5%)

• Acquired after transfer (n=132, 32.3%)

• Was a surgical site infection (n=87, 21.3%)

• Was MRSA (n=60, 14.7%)

• Contributed to, or caused death (n=345, 84.4%).

4.7 Causes of deathSurgeons reported 2369 causes of death in 1718 (94.8%) audited deaths. Table 16 lists the ten most reported causes of death, based on their Read code description.

Table 16: Ten most reported causes of death, based on Read code description, in 1718 audited deaths

Cause of death based on Read code description Audited deaths

n %

Multiple organ failure 190 11.1

Septicaemia 166 9.7

Respiratory failure 149 8.7

Cardiac arrest, other than acute myocardial infarction 108 6.3

Acute myocardial infarction 105 6.1

Pneumonia or influenza 82 4.8

Heart failure 68 4.0

Ischaemic bowel 58 3.4

Pulmonary embolism 48 2.8

Cardiorespiratory failure 48 2.8

21 Twelve patients were reported to have acquired infection before and after transfer.


The next table shows the five most reported causes of death, based on Read code description, for audited deaths of patients aged under 70 years, as well as those aged 70 or more.

Table 17: Five most reported causes of death, based on Read code description, for audited deaths with age under 70 years and 70 years or more

Cause of death based on Read code descriptionAudited deaths

< 70 years old (n=562)

n %

Septicaemia 43 7.6


Subarachnoid haemorrhage 29 5.2


Intracerebral haemorrhage 22 3.9

Cause of death based on Read code descriptionAudited deaths

>= 70 years old (n=1156)

n %

Multiple organ failure 138 11.9

Septicaemia 123 10.6


Acute myocardial infarction 85 7.4

Pneumonia or influenza NOS 70 6.1



The next table shows the three most reported causes of death, based on Read code description, in each surgical specialty. When two or more causes are equal in numbers for ranking, they are listed in the same cell.

Table 18: Three most reported causes of death, based on Read code description, by surgical specialty

Surgical specialty

Three most reported causes of death based on Read code description

First Second Third

Cardiothoracic Heart failureRespiratory

failureMultiple organ

failure

General Multiple organ

failureRespiratory

failureSepticaemia

NeurosurgerySubarachnoid haemorrhage

Intracerebral haemorrhage

Severe head injury

Traumatic subdural haemorrhage

Ophthalmology * * *

OrthopaedicsAcute myocardial

infarction

Multiple organ failure

Respiratory failure

Cardiac arrest


Paediatrics * * *

Plastic * * *

UrologyMultiple organ failure

Respiratory failure* *

VascularAbdominal aortic aneurysm which

has ruptured


Acute myocardial Infarction


Surgeons reported that 243 (13.4%) audited deaths occurred within 24 hours of the most recent anaesthetic and there was an anaesthetic component to seven (2.9%) of these deaths.

4.7.1 Post-mortem examination

In 270 (14.9%) audited deaths, the surgeons reported that a post-mortem (PM) examination was performed, either by the Coroner (n=230, 85.2%) or the hospital (n=40, 14.8%). For 80 (29.6%) of these, the surgeons reported to have read the PM report at the time of completing the surgical case form, but only in thirteen (16.3%) deaths the surgeon had found the report to have contributed additional information, which if known, may have changed management.

In 413 (22.8%) audited deaths, the surgeons reported that a PM examination was not done (n=393, 95.2%) or was refused (n=20, 4.8%) and they would have preferred a PM in 73 (17.7%) of them.


4.8 In hindsightSurgeons reported that, with hindsight, they would have done things differently in 238 (13.1%) audited patient deaths.

Both the surgeons and assessors were asked about patient management in the following areas:

• Pre-operative management/preparation

• Decision to operate at all

• Choice of operation

• Timing of operation (too late, too soon, wrong time of day)

• Intra-operative/technical management of surgery

• Grade/experience of surgeon deciding

• Grade /experience of surgeon operating

• Post-operative care

For surgeons, the question was “Do you consider management could have been improved in the following areas?” and for assessors, the question was “Were there any areas of consideration, of concern or adverse events in any of the following areas?” Despite the difference in the question, there is a high level of observed agreement between the surgeons and the assessors (Table 19). The low kappa scores, however, suggest only slight to fair agreement when accounting for chance. This paradox of having a high observed agreement but a low kappa is due to the large number of agreement on the “No” responses from the surgeons and assessors, resulting in an imbalance in the marginal totals (Feinstein and Cicchetti, 1990; Cicchetti and Feinstein, 1990). For interpretation of the kappa statistic, please refer to page 18.

Table 19 also includes the agreed responses from the surgeons and assessors to the following questions:

• Was fluid balance an issue in this case?

• Would it be beneficial for this case to undergo root cause analysis?


Table 19: Level of agreement between participating surgeons’ self assessment and CHASM assessors’ evaluation on a number of areas relating to patient management

Patient management area

Agreement (%)

Kappa95%

CIP

valueComments

Pre-operative management / preparation

Yes = 4.5

No = 83.60.38

0.31 - 0.45

< 0.001High observed agreement on “No” response.

Kappa score indicates fair agreement.

Decision to operate at all

Yes = 2.1

No = 87.00.23

0.15 - 0.31



Choice of operation

Yes = 0.9

No = 92.50.19

0.09- 0.28


Kappa score indicates slight agreement.

Timing of operation

Yes = 1.9

No = 88.50.25

0.16 - 0.33



Intra-operative/technical management of surgery

Yes = 1.2

No = 93.50.30

0.19 - 0.41



Grade/experience of surgeon deciding

Yes = 0.1

No = 97.50.05

-0.05 - 0.15

< 0.001Very high observed agreement on “No” response.


Grade/experience of surgeon operating

Yes = 0.1

No = 96.60.07

-0.03 - 0.18

< 0.001Very high observed agreement on “No” response.


Post-operative care

Yes = 3.2

No = 86.90.35

0.27 - 0.44



Fluid balanceYes = 4.0

No = 83.20.33

0.26 - 0.41



Root cause analysis

Yes = 1.5

No = 80.30.18

0.12 - 0.24



In 1129 (62.3%) of the 1812 audited deaths, the surgeon did not think that patient management as specified in Table 19 could have been improved and the assessors did not identify any areas of consideration, concern, or adverse events in the patient’s management.


4.8.1 Potential deficiencies of care

CHASM assessors identified 663 potential deficiencies of care22 in 453 (25.0%) audited deaths, which were under the care of 259 surgeons. They classified them as follows:

• Area of consideration (n=389, 58.7%)

• Area of concern (n=185, 27.9%)

• Adverse event (n=71, 10.7%)

• Not reported (n=18, 2.7%)

Assessors considered that 386 (58.2%) of the 663 potential deficiencies of care identified were definitely, or probably, preventable. These preventable potential deficiencies of care were identified in 262 (14.5%) of the 1812 audited deaths. The table below shows the Read code description of the twelve most identified preventable deficiencies of care, by their frequency.

Table 20: The description and frequency of the top 12 preventable deficiencies of care identified by CHASM assessors in 1812 audited patient deaths

Description of preventable deficiencies of care

Number Percentage of

audited cases %

Decision to operate 28 1.5

Delay to surgery (i.e., earlier operation desirable) 28 1.5

Better to have done different operation or procedure 23 1.3

Delay in transfer to tertiary hospital 17 0.9

Delay in diagnosis 14 0.8

Post-operative care unsatisfactory 12 0.7

Poor documentation 12 0.7

Pre-operative assessment inadequate 11 0.6

Delay in transfer to surgical unit 9 0.5

Delay in recognising complications 7 0.4

Unsatisfactory medical management 7 0.4

Fluid balance unsatisfactory 7 0.4

The decision to operate was the most frequently reported potentially preventable deficiency of care during this reporting period. It refers to the clinical decision to operate or not operate, generally in elderly patients with advanced disease and other co-morbidities, with the benefit of hindsight. In some instances, the assessors noted that it was the patient or the family who wanted the surgeon to operate.

22 Please refer to section 1.3.2 Methods, on page 15 for an explanation of potential deficiencies of care.


Delay to surgery refers to delay before operation. It ranged from 14 hours to seven weeks between diagnosis and surgery. Repair of irreducible/strangulated femoral hernia, insertion of permanent pacemaker, internal fixation for fracture, surgical drainage and laparotomy, were some of the delayed surgery reported. In a few instances, the delay to surgery was due to change from an initial decision to treat conservatively, when the patient started to deteriorate.

Whether a different operation should have been performed, refers to the choice by the surgeon. In some instances, the assessor felt that the surgeon might have performed more limited surgery or taken a different surgical approach, as an option. Some assessors included literature on the best-practice surgical management for the clinical condition in their constructive feedback to the surgeon.

Delay in transfer to tertiary hospitals was mainly related to admissions to rural and district hospitals for patients who required specialist care, such as neurosurgery, cardiothoracic and plastic surgery, which were not available in the primary hospital. Some of the reasons identified for delay in transfer to a tertiary hospital are delay in reviewing clinical results, delay in making a decision to transfer at the referral hospital and the lack of critical-care beds at the tertiary hospital.

Delay in diagnosis was related to a number of factors. Assessors identified the diagnostic delay to be associated with clinicians of the emergency department, the medical team and the surgical team. Leaking abdominal aortic aneurysm, pneumothorax, hernia, intestinal obstruction, gastric perforation, septic arthritis and peri-prosthetic hip infection were reported as some delayed diagnoses. Diagnostic delays associated with emergency department and medical teams would inevitably lead to delayed referral to surgical team for treatment, i.e., delay in transfer to surgical unit.

Pre-operative assessment refers to inadequate preparation, assessment and investigation of patients. Some issues mentioned include lack of knowledge of patient’s medical history, lack of pre-anaesthetic assessment and poor interpretation of investigation results, which ultimately affect decision making to surgery and the choice of operation performed.

Both post-operative care, or medical management deemed unsatisfactory, refer to sub-standard care that is not consistent with protocols, such as premature feeding leading to aspiration, omission of vital medications, failure to treat sepsis and inappropriate management of fluid balance and coagulation.

Poor documentation was reported by assessors after a case notes review. It referred to poor record-keeping by surgical or other teams. Some issues reported included inconsistency of information recorded in notes, poor, or no, documentation of admission, lack of a pre-anaesthetic assessment, anaesthesia administration and the operation, or record of surgery.


The following figure shows the distribution of audited deaths with preventable deficiency of care identified by CHASM assessors, by surgical specialty. Due to the small numbers in identified deficiencies of care for the specialties of ophthalmology, otolaryngology, paediatric and plastic surgery (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Figure 21: Proportion of audited deaths with potential preventable deficiency of care identified by CHASM assessors by surgical specialty (n=1812)

All

VascularUrologyPlastic*

Paediatric*

Otolaryngology*

Orthopaedics

Ophthalmology*

Neurosurgery

General

Cardiothoracic

% of audited deaths with potential preventable deficiency of care indentified by CHASM assessors

Surg

ical

sp

ecia

lty

0 5 10 15 20

13

16.7

10

10

17.7

16.7

14


• The rate of potential prevention deficiency of care was highest among urological audited deaths (n=11, 17.7%), followed by general (n=130, 16.7%) and vascular (n=34, 16.7%).


4.9 DiscussionAs stated in the last report, the CHASM audit is based on self-reported data provided by surgeons. The reliability of the audit data is therefore limited by recall bias.

Generally, the audited deaths:

• Were mostly elderly, with a median age of 77 years

• Did not differ greatly in gender, with 54% males and 46% females

• Were mostly admitted as an emergency (n=1504, 83.0%)

• Were reported to :

– have moderate to severe systemic disease that limited function, or was a threat to life (ASA grade of either 3 or 4) (n=1300, 71.7%)

– be at considerable or expected risk of death before surgery (n=1072, 59.2%).

Regarding patient management, the majority of audited deaths:

• Had at least one operation (n=1601, 88.3%), in which the consultant surgeon decided 89 per cent and was in theatre for 69 per cent

• Were referred to ICU or HDU for care (n=1232, 68.0%)

• Had prophylaxis against venous thromboembolism (n=1473, 81.3%)

• Did not have:

– Any pre-operative delay or errors in confirmation of main surgical diagnosis (n=1647, 90.9%)

– Any definable post-operative complication (n=1239, 68.4%).

– Any potential deficiencies of care identified by CHASM assessors (n=1359, 75.0%).


CHASM assessors identified 386 potential deficiencies of care in 262 (14.5%) audited deaths that they considered definitely or probably preventable.

The following table compares the data on 12 indicators to track changes in the surgical management of the audited deaths as reported by surgeons and assessors, between this and the last reporting period.

Table 21: Change in surgical management of audited deaths as reported by surgeons and assessors over two 18-month periods up to 31 December 2010

No. and % of audited deaths Difference

Jan 2008 to June 2009

July 2009 to Dec 2010

No. %

Delay and/or problems with transfer

31 13.4 61 12.9 30 0.5

Elective surgery performed as planned

82 85.4 250 95.1 168 9.7*

Consultant surgeon in theatre 417 68.1 1103 68.9 686 0.8

Would have benefited from care at intensive care unit (ICU) or high-dependency unit (HDU)

18 5.7 42 7.2 24 1.5

Use of prophylaxis against venous thromboembolism

587 72.6 1473 81.3 886 8.7*

Pre-operative delay or errors in confirmation of main surgical diagnosis

73 9.0 165 9.1 92 0

Definable post-operative complications

238 29.5 573 31.6 335 2.1

Unplanned return to theatre 98 16 250 15.6 152 0.4

Unplanned admission to ICU 124 15.3 321 17.7 197 2.4

Unplanned re-admission within 30 days of surgery

23 2.8 65 3.6 42 0.8

Hospital acquired infection 193 23.9 409 22.6 216 1.3

Potential preventable deficiency of care identified by assessors

114 14.1 262 14.5 148 0.4

*Statistically significant (p<0.01).

There was a statistical difference in the data in two indicators between the two reporting periods. In this period, the proportion of audited deaths in which the patient had:

• elective surgery performed as planned, is 9.2 per cent more than in the last period. This difference is statistically significant, χ2(1, N=359) = 9.397, p=0.002

• prophylaxis against venous thromboembolism, is 8.7 per cent more than in the last period. It is also statistically significant, χ2(1, N=2497) = 22.684, p=0.000.

Part B

Health Service Figures


5. Health service resultsFor this reporting period, all public hospitals were under the jurisdiction of former area health services (AHS), hence the data is presented by AHS. In 2011, AHS were changed to local health districts (LHD) and the next CHASM report will present the data by LHD.

KEY POINTS

• The majority of audited deaths in all area health services:

– had an emergency admission

– were graded ASA 3 or 4

– had at least one operation.

• The majority of audited deaths in nearly all area health services:

– were older in females than males

– had cardiovascular, age and respiratory as the most common co-morbid factors

– had moderate to considerable perceived risk of death before surgery.

• Pre-operative transfer was higher in rural area health services.

• Across all area health services:

– consultant surgeons decided the majority of operations performed

– over 85 per cent of audited deaths with an elective admission had the operation performed as planned

– 50 to 73.1 per cent of audited deaths with an emergency admission had an operation within 24 hours

– 40 to 93 per cent of audited deaths with an elective admission had the consultant surgeon in theatre for at least one operation

– 56 to 93 per cent of audited deaths with emergency admissions had the consultant surgeon in theatre for at least one operation.

• The reported use of intensive care/high-dependency units across all area health services ranged from:

– 63 to 80 per cent for audited operative deaths

– 24 to 55 per cent for audited non-operative deaths

– 64 to 80 per cent for audited deaths where the patient had moderate to considerable perceived risk of death before surgery.

• Venous thromboembolism prophylaxis was used in 77 per cent or more of audited deaths across all area health services.

• The proportions of audited deaths with post-operative complications, unplanned return to theatre and unplanned admission to intensive care unit, were higher among those admitted electively than those as an emergency across all area health services.

• Pre-operative management was the most reported area in which management could have improved in nearly all area health services.


5.1 Demographics

5.1.1 Age and sex distribution

The following tables show the age and sex of 1812 audited deaths by area health service.

Table 22: Median age and sex of audited deaths by area health service (n=1812)

Area health service Male Female

n %Median

(interquartile range) age

n %Median

(interquartile range) age

Greater Southern 23 52.3 83 (66 - 88) 21 47.7 76 (63 - 88)

Greater Western 22 50.0 77 (74 - 84) 22 50.0 83 (78 - 86)

Hunter New England 230 58.5 72 (58 - 82) 163 41.5 77 (65 - 85)

North Coast 111 56.6 79 (70 - 85) 85 43.4 79 (67 - 87)

Northern Sydney Central Coast 122 49.2 76 (68 - 84) 126 50.8 87 (73 - 87)

South Eastern Sydney Illawarra 174 54.7 74 (63 - 82) 144 45.3 80 (69 - 87)

Sydney South West 155 54.2 73 (61 - 83) 131 45.8 81 (70 - 86)

Sydney West 138 48.8 71 (60 - 82) 145 51.2 77 (69 - 85)

NSW 975 53.8 75 (63 - 83) 837 46.2 80 (69 - 86)

• Generally, females were older than males, with an exception in the Greater Southern Area Health Service.

• In most area health services, there were more male than female deaths, except in Greater Western, Northern Sydney Central Coast and Sydney West.


Table 23: Age group and sex distribution of audited deaths by area health service (n=1812)

Area health service Sex Age Group (years) %

0 – 34 35 – 64 65 – 79 80+

Greater SouthernFemale 0.0 28.6 28.6 42.9

Male 4.3 13.0 21.7 60.9

Greater WesternFemale 4.5 0.0 22.7 72.7

Male 0.0 9.1 45.5 45.5

Hunter New EnglandFemale 4.3 18.4 33.7 43.6

Male 5.7 27.0 31.7 35.7

North CoastFemale 0.0 15.3 34.1 50.6

Male 0.0 15.3 35.1 49.5

Northern Sydney Central CoastFemale 0.8 12.7 28.6 57.9

Male 0.0 15.6 45.9 38.5

South Eastern Sydney IllawarraFemale 2.1 18.1 26.4 53.5

Male 6.3 19.5 42.0 32.2

Sydney South WestFemale 1.5 13.0 27.5 58.0

Male 3.2 25.8 38.1 32.9

Sydney WestFemale 0.7 17.9 33.8 47.6

Male 4.3 29.7 34.1 31.9

NSWFemale 1.8 16.0 30.3 51.9

Male 3.7 22.4 37.1 36.8

Note: Percentages do not add to 100 due to rounding.


5.2 AdmissionsThe following figure shows the distribution of the audited deaths by admission type and area health service. In 34 cases (1.9%) the patient’s admission type was not recorded.

Figure 22: Admission types of audited deaths by area health service (n=1812)

Area health service

Au

dit

ed d

eath

s (%

)

Elective Emergency Not reported

0

20

40

60

80

100

NSWSydney West

Sydney South West



NorthCoast

Hunter New

England

GreaterWestern

GreaterSouthern

21 11 16 13 13 13 20 15 15

75 86 82 85 85 85 79 84 83

Note: Percentages do not add to 100, due to rounding.

• Across all area health services, 75 per cent or more of the audited deaths had an emergency admission.


5.3 TransfersPre-operative transfer of the patient from one hospital to another may be needed, due to lack of diagnostic facilities, lack of staff and/or facilities for safe and effective therapy in the referring hospital, a need for a higher level of care, or for a specialty service. Surgeons recorded pre-operative transfer in 474 (26.2%) audited deaths. The figure below summarises data on pre-operative patient transfer by area health service.

Figure 23: Pre-operative transfer of audited deaths by area health service (n=1812)

Area health service

Au

dit

ed d

eath

s (%

)

Transferred pre-operatively Not transferred pre-operatively Not reported

0

20

40

60

80

100

NSWSydney West

Sydney South West



NorthCoast

Hunter New

England

GreaterWestern

GreaterSouthern

36 39 32 24 14 25 28 29 26

64 59 67 74 85 74 72 71 73

• The proportion of pre-operative transfer was higher in rural area health services. Greater Western (n=17, 38.6%), Greater Southern (n=16, 36.4%) and Hunter New England (n=125, 31.8%). This may be indicative of geographical factors and the facility profiles of these areas.


5.4 Assessment

5.4.1 American Society of Anesthesiologists (ASA) grade

A description of the ASA grades is shown at Table 10 in Section 4.4.1 on page 35 of this report.

ASA grades were reported in 1740 (96.0%) audited deaths, with the majority (n=1300, 71.7%) being either 3 or 4. The following figure shows the ASA grades of the audited deaths by area health service.

Figure 24: Distribution of audited deaths by ASA grade and area health service (n=1812)

Area health service

Au

dit

ed d

eath

s (%

)

0

20

40

60

80

100

NSWSydney West

Sydney South West



NorthCoast

Hunter New

England

GreaterWestern

GreaterSouthern

73

ASA 4

ASA 3

ASA 2

ASA 1

ASA 5

ASA 6

Not reported

24

36

74

5

16

34

9

25

59

34

14

14

43

4

29

15

7

36

8

41

76

43

29

31

12

3

34

7

19

27

112

43

29

34

93

42

39

32

12

3

40

310

32

11

4

• The proportion of audited deaths with an ASA grade 1 or 2 was highest in Northern Sydney Central

Coast (n=81, 26.0%), followed by Greater Southern (n=9, 20.5%).


5.4.2 Malignancy

Surgeons reported the presence of malignancy in 469 (25.9%) audited deaths. The following figure shows the proportion of audited deaths with reported malignancy by area health service.

Figure 25: Presence of malignancy in audited deaths by area health service (n=1812)

Area health service

Au

dit

ed d

eath

s (%

)

0

20

40

60

80

100

NSWSydney West

Sydney South West



NorthCoast

Hunter New

England

GreaterWestern

GreaterSouthern

Not reportedNo malignancy presentMalignancy present

59

36

75

23

65

31

63

29

65

28

65

22

78

18

66

27

67

26

• The presence of malignancy in audited deaths was reported in all area health services.

• Greater Southern had the highest proportion of audited deaths with reported malignancy (n=16, 36.4%).

5.4.3 Co-morbid factors

Co-morbid factors refer to co-existing medical conditions or disease processes additional to the primary surgical diagnosis. Surgeons reported significant co-morbid factors that increased the risk of death in 1619 (89.3%) audited deaths. The table below shows the proportion of audited deaths by reported co-morbid factors and area health service.

Table 24: Co-morbid factors in audited deaths by area health service (n=1619)

Area health service Cardiovascular Age Respiratory Renal

Greater Southern 73.7 57.9 50.0 42.1

Greater Western 73.8 61.9 26.2 28.6

Hunter New England 64.8 48.1 35.5 27.9

North Coast 77.0 52.4 48.1 31.6

Northern Sydney Central Coast 72.1 54.0 45.6 27.0

South Eastern Sydney Illawarra 67.0 49.4 37.1 26.2

Sydney South West 76.2 57.1 43.3 26.1

Sydney West 63.0 44.0 40.1 29.2

NSW 69.6 51.0 40.7 28.2


Area health serviceNeurological / psychiatric

DiabetesAdvanced

malignancyObesity Hepatic

Greater Southern 13.2 10.5 13.2 13.2 2.6

Greater Western 14.3 11.9 4.8 9.5 2.4

Hunter New England 18.2 12.9 14.1 9.1 7.0

North Coast 16.6 20.3 12.3 12.8 10.2


22.1 14.2 12.8 7.5 4.4


15.7 17.6 12.0 8.6 6.0

Sydney South West 14.2 16.9 8.4 10.0 7.3

Sydney West 21.0 22.6 10.9 12.5 8.2

NSW 17.7 16.8 11.7 10.0 6.9

• Among the audited deaths with co-morbid factors (n=1619), the most common factors increasing the risk of death were cardiovascular (n= 1127, 69.6%), age (n=826, 51.0%) and respiratory (n=659, 40.7%).

• The proportion of audited deaths with:

– Cardiovascular co-morbid factors was highest in North Coast and Sydney South West

– Age co-morbid factors was highest in Greater Western and Sydney South West

– Respiratory co-morbid factors was highest in Greater Southern and North Coast

– Renal co-morbid factors was highest in Greater Southern

– Neurological/psychiatric co-morbid factors was highest in Northern Sydney Central Coast and Sydney West

– Diabetes co-morbid factors was highest in Sydney West and North Coast

– Advanced malignancy co-morbid factors was lowest in Greater Western

– Obesity as a co-morbid factor was highest in Greater Southern

– Hepatic co-morbid factors was highest in North Coast


5.4.4 Risk of death before surgery

Surgeons reported the perceived risk of death before surgery in 1698 (93.7%) of the 1812 audited deaths. Many of these (n=1072, 59.2%) were reported to be at considerable or expected risk. A small number (n=43, 2.4%) were reported to be at minimal risk. The following figure shows the perceived risk of death before surgery of the audited deaths by area health service.

Figure 26: Perceived risk of death before surgery of audited deaths by area health service (n=1812)

0 20 40 60 80 100

NSW

Sydney West

Sydney South West



North Coast

Hunter New England

Greater Western

Greater Southern

Audited deaths (%)

Are

a h

ealt

h s

ervi

ce


11 119 48 516

5 1416 41 1411

4 1623 44 68

1 1326 43 710

1 1323 46 711

2 1424 54 34

1 1127 42 712

3 1320 47 89

2 1423 46 69

• Over a quarter of audited deaths in Greater Southern (n=12, 27.3%) were reported to have minimal to small risk of death before surgery.

• South Eastern Sydney Illawarra had the highest proportion of audited deaths with considerable or expected risk of death before surgery (n= 215, 67.7%).


The following figure shows the distribution of audited deaths where the patient underwent at least one operative procedure (n=1601, 88.4%), by perceived risk of death before surgery and area health service. Many (n=953, 59.6%) were perceived by surgeons to be of considerable, to expected, risk of death.

Figure 27: Distribution of audited operative deaths by perceived risk of death before surgery and area health service (n=1601)

Area health service

Au

dit

ed d

eath

s (%

)

0

20

40

60

80

100

NSWSydney West

Sydney South West



NorthCoast

Hunter New

England

GreaterWestern

GreaterSouthern

8

13

8

53

5

41

6

13

19

16

6

23

410

44

16

45

11

27

13

47

11

26

11

43

13

29

9

6

47

10

21

14

15

5 4 6 4

57

5

24

12

47

10

24

13

3

3 2


• The proportion of audited deaths where the patient had an expected risk of death before surgery and underwent an operation, was highest in Hunter New England (n=56, 16.0%), followed by Greater Western (n=5, 15.6%) and Sydney West (n=37, 14.1%).


5.5 Management

5.5.1 Operation

Surgeons reported 2193 operations in 1601 (88.4%) audited deaths. The following figure shows the distribution of audited deaths in each area health service by their operative status.

Figure 28: Distribution of audited deaths, by operative status and area health service (n=1812)

0 20 40 60 80 100

NSW

Sydney West

Sydney South West



North Coast

Hunter New England

Greater Western

Greater Southern

Audited deaths (%)

Are

a h

ealt

h s

ervi

ce

No operationHad operation

91 9

73 27

89 12

89 11

88 1285 15

89 1193 7

88 12

• Most of the audited deaths had at least one operation in all area health services.

• Over a quarter of the audited deaths (n=12, 27.3%) in Greater Western had no operations.

Admission data was recorded in 1778 (98.1%) audited deaths, including 274 (15.1%) elective (planned) and 1504 (83.0%) emergency admissions. The next two figures show the operative status of elective and emergency admissions by area health service.

Figure 29: Distribution of audited deaths with elective admissions, by operative status and area health service (n=274)

Area health service

Au

dit

ed d

eath

s w

ith

el

ecti

ve a

dm

issi

on

(%

)

0

20

40

60

80

100

NSWSydney West

Sydney South West



NorthCoast

Hunter New

England

GreaterWestern

GreaterSouthern

100 100 97 100 100 95 98 95 97


• A total of seven (2.6%) audited deaths with an elective admission did not have an operation. They were distributed among four area health services.


Figure 30: Distribution of audited deaths with emergency admissions, by operative status and area health service (n=1504)

Area health service

Au

dit

ed d

eath

s w

ith

em

erg

ency

ad

mis

sio

n (

%)

0

20

40

60

80

100

NSWSydney West

Sydney South West



NorthCoast

Hunter New

England

GreaterWestern

GreaterSouthern

88 68 87 87 86 83 87 92 87


12 32 13 13 14 17 13 8 13

• Almost one-third of the audited deaths with an emergency admission in Greater Western (n=12, 31.6%) did not have an operation.

• Sydney West had the highest proportion of audited deaths with an emergency admission and an operation (n=219, 92.4%).

The timing of the first operation of the audited deaths is shown in the next two figures by admission types and area health service.

Figure 31: Timing of first operation of audited deaths with elective admissions, by area health service (n=267)23

12 32 13 13 14 17 13 8 13

Area health service

Au

dit

ed d

eath

s w

ith

el

ecti

ve a

dm

issi

on

(%

)

0

20

40

60

80

100

NSWSydney West

Sydney South West



NorthCoast

Hunter New

England

GreaterWestern

GreaterSouthern

100 100 89 100 94 95 95 88 93

Emergency (<24hrs) Scheduled Emergency (>= 24 hours after admission) Elective Immediate (<2hrs) Not reported

• The timing of the first operation in 19 (7.1%) audited operative deaths with an elective admission was reported as being immediate, emergency or scheduled emergency, in five area health services.

23 This figure is the total number of audited deaths where the patient was admitted electively and had at least one operation.


Figure 32: Timing of first operation of audited deaths with emergency admissions, by area health service (n=1301)24

Area health service

Au

dit

ed d

eath

s w

ith

em

erg

ency

ad

mis

sio

n (

%)

0

20

40

60

80

100

NSWSydney West

Sydney South West



NorthCoast

Hunter New

England

GreaterWestern

GreaterSouthern

31 35 39 20 20 22 20 25 26

21

3829

40 3242

3036 34

35

2726

31 36

27

3632 31

6 2 2 3 2 2 1 2

74 7 9 7 12 6 7

Emergency (<24hrs) Scheduled Emergency (>= 24 hours after admission) ElectiveImmediate (<2hrs) Not reported

• Greater Western had the highest proportion of audited operative deaths where the patient had an emergency admission and an operation within 24 hours (n=19, 73.1%).

• Only half of the audited operative deaths with an emergency admission had an operation within 24 hours in Sydney South West (n=98, 50.0%).

24 This figure is the total number of audited deaths where the patient had an emergency admission and at least one operation.


The involvement of consultant surgeons in the audited deaths is examined by their presence in theatre, i.e., performed, assisted, or attended the operation. The following table shows the proportion of audited deaths with a consultant surgeon present in theatre in the three reported operations, by area health service.

Table 25: Proportion of audited deaths with consultant surgeons’ involvement in three operations performed, by area health service

Area Health Services

Operation 1 (n=1601) Operation 2 (n=445) Operation 3 (n=148)

Deciding %

Operating %

Assisting/ in theatre

%

Deciding %

Operating %


%

Deciding %

Operating %


%

Greater Southern

87.5 82.5 10.0 100 88.9 11.1 n.a. n.a. n.a.

Greater Western

93.8 75.0 3.1 100 83.3 0 100 100 0

Hunter New England

93.1 55.5 8.6 83.6 53.4 6.8 88.5 65.4 3.8

North Coast 86.8 66.7 6.3 78.6 69.6 3.6 78.6 71.4 0


91.3 63.5 9.6 82.3 59.7 1.6 76.2 57.1 9.5


88.1 60.6 5.6 88.1 65.7 4.5 81.0 47.6 9.5

Sydney South West

87.5 58.0 7.8 71.6 56.8 6.2 72.4 51.7 6.9

Sydney West 85.6 43.7 6.8 75.8 52.7 2.2 91.2 70.6 5.9

NSW 89.1 58.2 7.1 80.2 59.8 4.3 82.4 61.5 6.1

n.a.= Not applicable due to nil operation reported

• Consultant surgeons decided the majority of operations performed in all area health services.

• The proportion of audited deaths with the consultant surgeon operating, assisting or present in theatre was:

– Above the State average of 65.7 per cent in four area health services

– Highest in Greater Southern


The following figures show the presence of consultant surgeons in theatre in audited operative deaths with elective and emergency admissions by area health service.

Figure 33: Distribution of audited deaths with elective admissions and consultant surgeons in theatre for at least one operation, by area health service (n=267)

Area health service

Au

dit

ed o

per

ativ

e d

eath

s w

ith

ele

ctiv

e ad

mis

sio

n (

%)

0

20

40

60

80

100

NSWSydney West

Sydney South West



NorthCoast

Hunter New

England

GreaterWestern

GreaterSouthern

89 40 79 72 81 93 86 83 82

No report of consultant in theatreConsultant in theatre

11 21 28 19 8 15 18 1860

• The proportion of audited deaths with elective admissions and consultant surgeons in theatre for at least one operation was:

– Above the State rate of 82 per cent in four area health services

– Highest in South Eastern Sydney Illawarra.

Figure 34: Distribution of audited deaths with emergency admissions and consultant surgeons in theatre for at least one operation, by area health service (n= 1301)

Area health service

Au

dit

ed o

per

ativ

e d

eath

s w

ith

em

erg

ency

ad

mis

sio

n (

%)

0

20

40

60

80

100

NSWSydney West

Sydney South West



NorthCoast

Hunter New

England

GreaterWestern

GreaterSouthern

93 85 64 75 74 64 63 56 66

No report of consultant in theatreConsultant in theatre

7 36 25 26 36 37 44 3415

• The proportion of audited deaths with emergency admissions and consultant surgeons in theatre for at least one operation was:

– Above the State rate of 66.2 per cent in four area health services

– Highest in Greater Southern.


5.5.2 Use of high-dependency and intensive care units

The reported use of high-dependency and intensive care units in 1232 or 68 per cent of audited deaths was examined by operative status and perceived risk of death before surgery, at each area health in the next two figures.

Figure 35: Use of intensive care or high-dependency unit in audited deaths, by operative status and area health service (n=1812)

0 20 40 60 80 100

NSW

Sydney West

Sydney South West



North Coast

Hunter New England

Greater Western

Greater Southern

Audited deaths with ICU/HDU care (%)

Are

a h

ealt

h s

ervi

ce


7355

8039

7535

7240

7225

6324

6741

7448

7325

• The proportions of audited deaths, with or without operation, had reported use of intensive care or high-dependency care units were:

– Above the State rates in South Eastern Sydney Illawarra and Northern Sydney Central Coast

– Highest in South Eastern Sydney Illawarra

• The reported use of intensive care or high-dependency care units in audited operative deaths was:

– Above the State rate of 71.8 per cent in five area health services

– Highest in Sydney South West

• The reported use of intensive care or high dependency care units in audited non-operative deaths was:

– Above the State rate of 39.6 per cent in three area health services

– Highest in South Eastern Sydney Illawarra.


Figure 36: Use of intensive care or high-dependency unit in audited deaths, by surgeons’ perceived risk of death before surgery and area health service (n=1812)

0 20 40 60 80 100

NSW

Sydney West

Sydney South West



North Coast

Hunter New England

Greater Western

Greater Southern

Audited deaths with reported use of ICU/HDU (%)

Are

a h

ealt

h s

ervi

ce


7 1310 60101250 1515

2020 48

1720 44 910

1322 49 791 1324 55 25

1 1127 44 512

1 1520 50 68

1 1522 49 58

2

4 4

2 8

• The reported use of ICU or HDU in audited deaths:

– with minimal to small perceived risk of death before surgery, were above the State rate of 9.3 per cent in four area health services

– With moderate to considerable risk of death before surgery, were below the State rate of 70.9 per cent in six area health services

– With expected risk of death before surgery, was above the State rate of 14.7 per cent in three area health services.

5.5.3 Venous thromboembolic prophylaxis

Surgeons reported the use of venous thromboembolic (VTE) prophylaxis in 1473 or 81.3 per cent of audited deaths. The following figures show the reported use and type of VTE prophylaxis in audited deaths by area health service.

Figure 37: Use of VTE prophylaxis in audited deaths, by area health service (n=1812)

0 20 40 60 80 100

NSW

Sydney West

Sydney South West



North Coast

Hunter New England

Greater Western

Greater Southern

Audited deaths (%)

Are

a h

ealt

h s

ervi

ce

VTE prophylaxis - NoVTE prophylaxis - Yes

82 18

82 18

77 23

84 16

86 1577 23

83 1783 17

81 19

• The reported use of VTE prophylaxis in audited deaths was 77 per cent or more in all area health services.


Figure 38: Type of VTE prophylaxis used, by area health service (n=1473)

0 20 40 60 80 100

NSW

Sydney West

Sydney South West



North Coast

Hunter New England

Greater Western

Greater Southern

Audited deaths with reported use of VTE prophylaxis (%)

Are

a h

ealt

h s

ervi

ce

Compression Aspirin WarfarinHeparin TED stockings Other

• Heparin was the most widely reported type of VTE prophylaxis used in audited deaths, followed by thromboembolic deterrent (TED) stockings and compression.

• The use of aspirin as VTE prophylaxis was reported in six area health services.

VTE prophylaxis was not used or reported in 339 or 18.7 per cent of audited deaths. The figure below shows the reasons given by surgeons for not using VTE prophylaxis by area health service.

Figure 39: Reasons for not using VTE prophylaxis, by area health service (n=339)

Area health service

Au

dit

ed d

eath

s w

ith

ou

t V

TE p

rop

hyl

axis

(%

)

0

20

40

60

80

100

NSWSydney West

Sydney South West



NorthCoast

Hunter New

England

GreaterWestern

GreaterSouthern

25 75 44 39 31 54 33 57 45

Active decision to withhold Omission/error Reason not reportedNot appropriate

1110 22 13

12

25

11 6

75 43 48 44 35 52 36 42

• The main reason reported for not using VTE prophylaxis was that it was not appropriate at the time.

• Failure to use VTE prophylaxis due to omission or error, was reported in five (1.5%) of the 339 audited deaths at four area health services.


5.6 Clinical incidents

5.6.1 Pre-operative delay or error

Surgeons reported pre-operative delay or errors in confirmation of main surgical diagnosis in 165 (9.1%) audited deaths. Tables 26 and 27 indicate the reasons for delay or error and the associated clinical unit.

Table 26: Reasons for pre-operative delay or error in confirmation of surgical diagnosis, by area health service (n=165)

Area health service

Reasons for delay or error in confirmation of surgical diagnosis (%)

Unavoidable factors

Misinterpretation of results

Failure to do correct test

Inexperience of staff

Results not seen

Miscellaneous factors

Greater Southern * - - - - - -

Greater Western * - - - - - -

Hunter New England 28.0 20.0 22.0 16.0 4.0 26.0

North Coast 20.0 16.0 12.0 4.0 8.0 48.0


17.4 30.4 17.4 21.7 8.7 21.7


26.9 7.7 7.7 11.5 3.8 30.8

Sydney South West 0 5.0 20.0 5.0 0 55.0

Sydney West 29.4 11.8 5.9 11.8 0 35.3

NSW 22.4 16.4 15.2 12.1 4.2 35.2

*This data is omitted due to small numbers (n≤ 5).

Note: Percentages do not add to 100, as a pre-operative delay or error could be the result of one or more issues.

Table 27: Unit associated with pre-operative delay or errors in confirmation of surgical diagnosis, by area health service (n=165)

Area health serviceMedical unit %

Surgical unit %

GP %

Other %

Greater Southern * - - - -

Greater Western * - - - -

Hunter New England 42 34 10 28

North Coast 24 36 12 24

Northern Sydney Central Coast 21.7 17.4 8.7 43.5

South Eastern Sydney Illawarra 38.5 11.5 7.7 38.5

Sydney South West 30 10 25 45

Sydney West 23.5 17.6 11.8 52.9

NSW 32.1 24.2 11.5 35.8


Note: Percentages do not add to 100, as a pre-operative delay or error could be attributed to one or more unit.


5.6.2 Post-operative complications

Surgeons reported a definable post-operative complication in 573 (31.6%) audited deaths across all area health services. They also reported a delay in recognising the complications in 37 (6.5%) of these deaths distributed among six area health services. The following figure shows the distribution of audited operative deaths with post-operative complications, by admission type and area health service.

Figure 40: Proportion of audited operative deaths with post-operative complications by admission type and area health service (n=1568)25

0 20 40 60 80 100

NSW

Sydney West

Sydney South West



North Coast

Hunter New England

Greater Western

Greater Southern

Audited operative deaths with post-operative complications (%)

Are

a h

ealt

h s

ervi

ce

EmergencyElective

7032

6238

7023

6131

6042

5224

6430

5236

6731

• The proportion of audited operative deaths with post-operative complications was higher among those admitted electively than those admitted as an emergency, across all area health services.

• In five area health services, the proportion of audited operative deaths with an elective admission and post-operative complications was above the State rate of 61 per cent.

25 The total number of audited deaths of which the patient had an operation and with admission data reported by surgeons.


The following table shows the types and frequency of reported post-operative complications, by area health service.

Table 28: Description of post-operative complications, by area health service (n=573)

Area health service

Post-operative complications (%)Significant

post-operative bleeding

Procedure related sepsis

Tissue ischaemia

Anastomotic leak

Vascular graft

occlusion

Endoscopic perforation

Other surgical

complications

Greater Southern 13.3 0 6.7 13.3 0 0 73.3

Greater Western 6.7 20.0 13.3 20.0 0 0 60

Hunter New England 15.8 13.9 5.9 6.9 2.0 2.0 52.5

North Coast 15.9 12.7 6.3 7.9 3.2 3.2 47.6

Northern Sydney Central Coast 13.8 11.5 9.2 11.5 3.4 2.3 54

South Eastern Sydney Illawarra 13.9 8.9 9.9 6.9 3.0 0.0 57.4

Sydney South West 15.5 8.2 23.6 8.2 5.5 0.0 56.4

Sydney West 6.3 15 8.8 12.5 1.3 1.3 63.8

NSW 13.4 11.3 11.2 9.1 3.0 1.2 56.0

Note: Percentages do not add to 100, as more than one post-operative complication may have been reported per death.


5.6.3 Unplanned return to theatre

Surgeons reported an unplanned return to theatre in 250 (15.6%) of the 1601 audited operative deaths. The following figure shows their distribution by area health service and admission type. Due to small numbers for Greater Southern and Greater Western (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Figure 41: Distribution of audited operative deaths with an unplanned return to theatre by admission type and area health service (n=1568)26

0 10 20 30 40

NSW

Sydney West

Sydney South West



North Coast

Hunter New England

Greater Western*

Greater Southern*

Audited operative deaths with unplanned return to theatre (%)

Are

a he

alth

ser

vice

EmergencyElective

2814

3518

2313

2514

1513

2413

3214

* This data is omitted due to small numbers (n≤ 5).

• In all area health services, the proportion of audited operative deaths with unplanned return to theatre was higher among those who had an elective admission than those were emergency admissions.

• In three area health services, the proportion of audited operative deaths with an elective admission and unplanned return to theatre was above the State rate of 24.7 per cent.

26 The total number of audited deaths of which the patient had an operation and with admission data reported by surgeons.


5.6.4 Unplanned admission to ICU

Surgeons reported an unplanned admission to ICU in 321 (17.7%) audited deaths. The following figure shows their distribution, by area health service and admission type. Due to small numbers for Greater Southern and Greater Western (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Figure 42: Distribution of audited operative deaths with an unplanned admission to ICU, by admission type and area health service (n=1778)27

0 10 20 30 40 50

NSW

Sydney West

Sydney South West



North Coast

Hunter New England

Greater Western*

Greater Southern*

Audited patients with unplanned admission to ICU (%)

Are

a h

ealt

h s

ervi

ce

EmergencyElective

3611

4117

2914

3315

2816

3617

3917


• In all area health services, the proportion of audited deaths with unplanned admission to ICU was higher among those with an elective admission than those with an emergency admission.

27 The total number of audited deaths with admission data reported by surgeons.


5.6.5 Unplanned readmission within 30 days of surgery

Surgeons reported an unplanned readmission within 30 days of surgery in 65 (3.6%) audited deaths across all area health services. The following figure shows their distribution by area health service and admission type. Due to small numbers for Greater Southern and Greater Western (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Figure 43: Distribution of audited deaths with an unplanned readmission within 30 days by admission type and area health service (n=1812)

0 5 10 15 20

NSW

Sydney West

Sydney South West



North Coast

Hunter New England

Greater Western*

Greater Southern*

Audited patients with unplanned readmission within 30 days (%)

Are

a h

ealt

h s

ervi

ce

72

23

23

63

113

124

33

EmergencyElective

• In three area health services, the rate of unplanned re-admission within 30 days among audited deaths with an elective admission, was three times higher than those with an emergency admission.

• In two area health services, the rate of unplanned re-admission within 30 days among audited deaths with an emergency admission, was higher than those with an elective admission.


5.6.6 Fluid balanceFluid balance was reported by surgeons as an issue in 123 (6.8%) audited deaths. The following figure shows the distribution of reported fluid balance issues by area health service. Due to small numbers for Greater Southern and Greater Western (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Figure 44: Distribution of audited deaths with a reported issue in fluid balance, by area health service (n=1812)

Area health service

Au

dit

ed d

eath

s (%

)

0

3

6

9

12

NSWSydney West

Sydney South West



NorthCoast

Hunter New

England

Greater Western*

Greater Southern*

88 68 4 11 6 10 6 6 7


• In two area health services, the proportion of audited deaths with a reported issue in fluid balance was higher than the State rate of 6.8 per cent.

5.6.7 Hospital infectionThe following table shows the proportion of audited deaths with reported infection by area health service. Where small number is noted (n ≤ 5), this data is omitted, to preserve privacy and data confidentiality.

Table 29: Reported infection in audited deaths, by area health service (n=1812)

Area health service

Audited deaths with reported

surgical site infection

Audited deaths with reported

MRSA infection

Audited deaths with reported infection that contributed to

death

n % n % n %

Greater Southern * * * * *

Greater Western * * * 7 15.9

Hunter New England 16 4.1 * * 71 18.1

North Coast 11 5.6 6 3.1 38 19.4

Northern Sydney Central Coast 14 5.6 * * 57 23.0

South Eastern Sydney Illawarra 14 4.4 15 4.7 54 17.0

Sydney South West 13 4.5 11 3.8 54 18.9

Sydney West 14 4.9 17 6.0 62 21.9

NSW 87 4.8 60 3.3 345 19.0

* This data is omitted due to small numbers (n≤ 5).Note: These figures are based on surgeon report only. They are not a true indicator of infection rates within an area health service.


5.6.8 Areas for improvement

Surgeons considered that management could have been improved in 679 (37.5%) audited deaths. Pre-operative management (n=151, 8.3%), decision to operate (n=103, 5.7%) and post-operative care (n= 99, 5.5%) were the three most reported areas in which management could have been improved. The following table shows the distribution of these by area health service.

Table 30: Proportion of audited deaths for three most reported areas of patient management which could have been improved at each area health service (n=679)

Area health servicePre-operative

management %Decision to operate %

Post-operative care %

Greater Southern * * *

Greater Western * * *

Hunter New England 11.7 5.6 4.3

North Coast 9.7 8.7 4.1

Northern Sydney Central Coast 8.5 6.5 6.5

South Eastern Sydney Illawarra 6.9 4.1 5.0

Sydney South West 6.6 4.2 5.9

Sydney West 6.0 4.9 6.7

NSW 8.3 5.7 5.5

* This data is omitted, due to small numbers (n≤ 5).

• Pre-operative management was the most reported area in which management could have improved in nearly all area health services, except Sydney West, which had post-operative care (n=19, 6.7%).


5.7 Causes of deathSurgeons reported 2369 causes of death in 1718 (94.8%) audited deaths. The next table lists the top five most reported causes of death, based on their Read code description, by area health service. Due to small numbers for Greater Southern and Greater Western (n ≤ 5), some of this data is omitted, to preserve privacy and data confidentiality.

Table 31: Five most reported cause of death, based on Read code description, by area health service (n=1718)28

Area health service

Reported cause of death


n (%)

Respiratory failure n (%)

Cardiac arrest n (%)

Acute myocardial infarction

n (%)

Septicaemia n (%)

Greater Southern 6 (15.4) * * * *

Greater Western * * * * 9 (24.4)

Hunter New England 35 (9.3) 25 (6.6) 19 (5.1) 21 (5.6) 33 (8.7)

North Coast 26 (14.1) 16 (8.6) 18 (9.7) 17 (9.2) 19 (10.2)


33 (13.9) 25 (10.5) 13 (5.5) 21 (8.8) 29 (12.2)


23 (7.6) 21 (7) 9 (3) 14 (4.7) 19 (6.3)

Sydney South West 38 (14) 31 (11.4) 25 (9.2) 15 (5.5) 29 (10.7)

Sydney West 27 (9.9) 30 (11) 14 (5.1) 10 (3.7) 19 (6.9)

* This data is omitted due to small numbers (n≤ 5).

5.8 DiscussionThe data presented in this part of the report shows the similarities, as well as the differences, in the audited deaths and their surgical management among the eight area health services. As discussed previously, the reliability of the CHASM data is limited by recall bias, due to its data collection method. Area health services are encouraged to examine the data against their service records and advise CHASM of any major discrepancy.

CHASM will continue to monitor and report annually on this data. The reporting of data at the local health district level will start from 2011.

28 The total number of audited patients with cause of death data reported by surgeons.


Appendix 1

Collaborating Hospitals’ Audit of Surgical Mortality

Terms of Reference

1. Name and purpose of the committee

The committee is known as the Collaborating Hospitals, Audit of Surgical Mortality (CHASM) committee. Its purpose is to review deaths that occur within 30 days after an operation or during the last hospital admission under the care of a surgeon, irrespective of whether an operation has been performed or not. The committee undertakes the following functions:

(a) Review functions

– To undertake, oversee, and co-ordinate a systematic audit of surgical mortality in NSW, using peer review processes.

– To review deaths associated with surgical care, identify potentially preventable factors associated with these cases and provide confidential feedback to the surgeons involved.

– To contribute surgical expertise to the preparation, analysis and interpretation of regular reports derived from de-identified aggregate data and make recommendations for appropriate action.

– To regularly review the committee’s functions and activities, including maintenance of security and confidentiality of case data.

– To share with the Special Committee Investigating Deaths Under Anaesthesia (SCIDUA) the following:

• Notification data on deaths that occur while under, or as a result of, or within 24 hours after, the administration of an anaesthetic or a sedative drug

• The audit findings of these deaths.

– To contribute surgical expertise to the review of clinical incidents involving surgical care and make recommendations for system improvement.

(b) Referrals to the committee

– To promote the systematic clinical review of deaths associated with surgical care among surgeons and their professional organisations.

– To receive notifications of deaths associated with surgical care from individual surgeons, public health organisations, private hospitals and day procedures centres and the NSW State Coroner.

(c) Obtaining information

– To obtain information, including confidential medical information, case notes and opinions relevant to deaths associated with surgical care from:

(i) Individual surgeons, in relation to cases that have been notified to the committee


(ii) Public health organisations and private health facilities in relation to cases being reviewed by the committee.

– To obtain expert advice and opinions relevant to deaths associated with surgical care from external assessors (including individual surgeons and such other persons or bodies as the committee considers appropriate) to assist the committee to perform its functions.

(d) Reporting and feedback

To provide information on, or relevant to, the outcome of reviews:

– Through feedback to individual surgeons involved in the care of the deceased patient

– Through provision of reports of de-identified aggregate data

(i) To public health organisations and private health facilities to assist in improving effective and timely care

(ii) To the Royal Australasian College of Surgeons for the purpose of maintenance of standards (including benchmarking) and education.

2. Authority by which the committee is established

The committee is constituted under Section 20 of the Health Administration Act 1982 and all committee members are appointed by the Minister for Health. The committee’s documents are privileged from subpoena under Section 23 of the same Act.

3. Membership of the committee (including establishment of quorum)

The committee currently consists of the following members:

– A/Prof Michael Fearnside, AM, Chair

– Dr Robert Costa, Deputy Chair and Chair of the NSW State Committee of RACS

– Dr Allysan Armstrong-Brown, anaesthetist

– Dr Graham Beaumont, human factors specialist

– Prof Belinda Bennett, Professor of Health Law

– Dr Lewis Chan, urologist

– A/Prof Anthony Eyers, colorectal surgeon

– A/Prof John Graham, vascular surgeon

– Dr Warren Hargreaves, general surgeon

– Prof John Hilton, forensic pathologist

– Professor Clifford Hughes, AO, Chief Executive Officer, CEC

– Dr Michael King, general surgeon

– Dr Steven Leibman, general surgeon

– Dr Hugh Martin, AM, paediatric surgeon

– Dr Charles Pain, Director Health Systems Improvement

– Dr David Robinson, vascular surgeon

– Prof Allan Spigelman, surgical oncologist

– Dr Warwick Stening, neurosurgeon

– A/Prof Peter Zelas, OAM, colorectal surgeon

The committee requires the presence of one-fifth of its members to establish a quorum.


4. Procedures for the appointment of members

The committee employs the following measures to publicise vacancies and invite interest for committee positions:

– Consulting with the Royal Australasian College of Surgeons (RACS)

– Consulting with specialists in the relevant surgical specialty

– Consulting with clinical governance at local health districts

Members are selected to reflect the interest of the surgical community as a whole and to achieve an appropriate mix of skills and experience on the committee. The number of other positions held by candidates is also considered, so that recommended candidates are not over-burdened.

When a candidate is identified for membership, the chair will discuss the nomination with the committee. Once the nomination is endorsed, a submission will be made to the Minister for Health to recommend appointment of the candidate as a member.

The Deputy Chair is an ex-officio member of the NSW State Committee of RACS.

The appointment of the Chair is approved by the Minister for Health, following submission of possible appointees by the Clinical Excellence Commission after consultation with the RACS.

5. Remuneration rates to be paid to members

Committee members are remunerated at rates that are set by the Premier’s Memorandum 2004-10, Guidelines for NSW Board and Committee Members: Appointments and Remuneration. The current rates, effective from 1 November 2004 are:

Chair Full day = $342 Half day = $171

Member Full day = $207 Half day = $104

Rates beyond the maximum must be approved by the Premier. It is important to note that under the Premier’s Memorandum 2004-10, public sector employees are not to be paid sitting fees for work on government committees.

6. Procedures and timeframe for the review of the committee

All members are appointed on a three-year term. A member can be renominated for a second, and possibly a third term. Thereafter, the member cannot be renominated for a period of three years.

7. How the committee communicates with its key stakeholders

The committee publishes its membership and information about CHASM at the following web address: http://www.cec.health.nsw.gov.au/programs/chasm#overview3

The Chair attends to enquiries and correspondence addressed to CHASM. The Chair also visits hospitals and local health districts on an ad hoc basis to promote CHASM and encourage surgeon participation. Similarly, Committee members promote CHASM and encourage surgeon participation at their respective local health districts.

CHASM communicates with participating surgeons by correspondence throughout the audit process. Annually, CHASM produces an individual surgeon report for all participating surgeons, to provide a summary of the analysis of the reported deaths that were under the care of the surgeon. CHASM also produces an annual report to the Minister for Health and local health districts.

http://www.cec.health.nsw.gov.au/programs/chasm#overview3


Appendix 2

CHASM staff during the reporting period

Executive and project staff based at the Clinical Excellence Commission

Professor Clifford Hughes, Chief Executive Officer

Dr Tony Burrell, Director, Patient Safety

Paula Cheng, Project Co-ordinator

Bruce Czerniec, Data Analyst

Adeline Nguyen, Project Officer

Lisa Huang, Project Officer (September 2009 to May 2010)

Ruth Murphy, Project Officer

Erin Gilmore, Project Assistant

Clinical Audit Managers based at former area health services

Nicole Smith, Greater Southern

Angela Bannon, Jane Bowen-Jones, Louise Robinson and Maree Carolan, Greater Western

Anne Barry, Hunter New England (from July 2008)

Maureen Lawrence, North Coast

Angie Pang, North Sydney and Central Coast

Ann Morgan, Cynthia Redmond, Joseph Pendon, Nancy Morieson and Wendy Bowker, South East Sydney and Illawarra

Belinda Irwin, Sydney South West (Eastern Zone)

Honora Hewett, Sydney South West (Western Zone)

Karenjit Kaur and Jean Cook, Sydney West


Appendix 3

Surgical Case Forms

First-line Assessment Forms

Second-line Assessment Forms

SCF Version 1.9.2

Study Number / /N S W 2 0 1

Page 1 of 7

SCF Version 1.9.2

Please return to:

Clinical Excellence CommissionCHASMSydney South Post ShopLocked Bag A4062SYDNEY SOUTH NSW 1235

Telephone: 02 9269 5530Facsimile: 02 9269 5597Email: [email protected]: www.cec.health.nsw.gov.au

COLLABORATING HOSPITALS' AUDIT OF SURGICAL MORTALITY

Royal AustralasianCollege of Surgeons

PRIVILEGED

Surgical Case Form

The information collected in this form is privileged under section 23 of the NSW Health Administration Act,1982.

By submitting this form to the Mortality Audit, I agree that Australian and New Zealand Audit of SurgicalMortality (ANZASM) may inform the Professional Standards Department of my involvement with the surgicalmortality audits, to confirm my compliance with Continuous Professional Developments (CPD) requirements.


54128

mailto:[email protected]:


http://www.cec.health.nsw.gov.auCOLLABORATING


PLEASE COMPLETE THIS SECTION FOR ALL PATIENTS

Patient Name

UMRN Birth Date/Age

Hospital

Consultant Surgeon

Name of any other Surgeon(s) / Trainees(s) to whom individual feedback should be sent

Anaesthetist(s)Please name

Study ID

Sex

Death Date

Admission Date

Discharge Date

Exclusion for terminal care patients

Was patient admitted specifically for terminal care and no operation performed?

If , please describe:

Yes No

If the patient was not admitted for terminal care and did not have an operation, please complete the remainder of this form.

THANK YOU

YES

Case Specialty

Hospital ID

ALL IDENTIFIERS WILL BE REMOVED BY CHASM ON RECEIPT OF COMPLETED FORM

If the patient was admitted for terminal care no further information is required. Please return this form to the CHASM Office

Malignancy

Trauma

Haemorrhage

SCF Version 1.9.2

1 Status of surgeon completing form:ConsultantAdvanced Surgical TraineeService RegistrarBasic Surgical TraineeGP SurgeonOther (specify)

Speciality of consultant surgeon in charge of patientGeneralVascularUrologyNeurosurgeryOrthopaedicsENT

OphthalmologyPaediatricsObs & GynaePlasticOral/MaxillofacialCardiothoracicOther (specify)

2 Admission TypeHospital StatusPatient Status

Elective EmergencyPrivate Public Co-locationPrivate Public Veteran

3

Main surgical diagnosis on admission (as suspected by clinicians after initial assessment)

Confirmed main surgical diagnosis (taking into account test results, operations, PM etc)

Final cause of death (taking all information into account, including PM)

Was a malignancy present, even if not the main diagnosis? Yes NoDid the malignancy contribute to death? Yes No Unknown

Were there significant co-existing factors increasing risk of death? Yes No(Tick all that apply)

4

Other factors5 ASA Grade

ASA 1

ASA 2

ASA 3

ASA 4

ASA 5

ASA 6

A normal healthy patient

A patient with mild systemicdiseaseA patient with severe systemicdisease which limits activity, but isnot incapacitating

A patient with an incapacitating systemicdisease that is a constant threat to life

A moribund patient who is not expected tosurvive 24 hrs, with or without anoperationA brain-dead patient for organ donation

6 Was the patient transferred pre-op? Yes No

Distance (km)(If No, go to Q7)

Hospital transferred from

Was there a delay in transfer?Yes No

Any problems with transfer?Was the transfer appropriate?

Was the level of care during transport appropriate?Yes No

Was there sufficient clinical information?

COLLABORATING HOSPITALS' AUDITOF SURGICAL MORTALITY

CardiovascularRespiratoryRenalHepatic

Neurological/psychiatricAdvanced malignancyDiabetesObesity

Age Other (specify)

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SCF Version 1.9.2

7 Was there a pre-op delay/error in confirmation of main surgical diagnosis? Yes No (If No, go to Q8)

Was the delay associated with:

Was this due to : (tick all that apply)

8 Was ICU/HDU used? Pre-operative Post-OperativeNo-op/1st 2nd Op 3rd Op 1st Op 2nd Op 3rd Op

Was ICU used?If not, should it have been?Was HDU used?If not, should it have been?

Yes No Yes No Yes No Yes No Yes No Yes No

Please describe the course to death.9(Additional space is available on page 7)

10 Was an operation performed within 30 days of death or during the last admission? Yes No

Yes NoWas this a consultant's decision?Yes NoWas a decision made to limit treatment?

11 Surgeon's view (before any surgery) of overall risk of death

Inexperience of staffFailure to do correct testMisinterpretation of results

Results not seenUnavoidable factorsOther (specify)


(If Yes, go to Q11, If No, tick as necessary)(If no operation was performed, please go to Q19)

GP Medical Unit Surgical Unit Other (specify)

It was not a surgical problemActive decision not to operatePatient refused operationRapid death


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SCF Version 1.9.2

12 Description of operation(s) (including relevant radiological or endoscopic procedures)

1)

2)

3)

Date / / Start time :(24 hr clock)

Date / / Start time :

Date / / Start time :13 Timing of Operation? Ist Op 2nd Op 3rd Op

ElectiveImmediate (< 2 hours)

Emergency (< 24 hours)Scheduled Emergency (> = 24 hours after admission)

14Was there an anaesthetist present at the operation?

1st Op 2nd Op 3rd Op

Was the operation abandoned on finding a terminalsituation?

15 Grades of surgeon(s) making decisions, operating, assisting and present in theatre

1st Op 2nd Op 3rd OpDeciding Operate Assist In Theatre Deciding Operate Assist In Theatre Deciding Operate Assist In Theatre

16 Yes No

Surgical complications relating to present admission (please tick all that apply)site

Was there a delay in recognising post-operative complications? Yes No

YesNo

YesNoN/A

ConsultantAdvanced Surgical Trainee

Registrar

Basic Surgical TraineeGP Surgeon

Other (specify)

None


Was there a definable post-operative complication?If Yes, please complete this question

(If No, go to Q17)

Anastomotic leak

Procedure-related sepsis

Significant post-op bleedingEndoscopic perforation

Tissue ischaemia

Vascular graft occlusionOther (specify)

Oesophageal Panc/biliary

Gastric Small Bowel

Colorectal

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SCF Version 1.9.2

17 Do you consider management could have been improved in the following areas?Yes No

Pre-operative management/preparationDecision to operate at all

Choice of operationTiming of operation (too late, too soon,wrong time of day)

Yes NoIntra-operative/technical managementof surgeryGrade/experience of surgeon deciding


Post-operative care

18 Was there an anaesthetic component to this death? Yes PossiblyNo

Yes No Don't Know

19 Was a post-mortem examination performed?

Yes - Hospital Yes - Coroner No Refused Unknown

If Yes, have you read the post-mortem report at the time of completing this form?If Yes, did the post-mortem contribute additional information, which if known,may have changed management?If No or Refused, would you have preferred a post-mortem?

20 Was DVT prophylaxis used? Yes No

If Yes (tick all that apply)

If No, state reasons: Not appropriate Active decision to withhold Omission/error

and please commenton why not used

21An area of CONSIDERATION is where the clinician believes areas of care COULD have been IMPROVED orDIFFERENT, but recognises that it may be an area of debate.

An area of CONCERN is where the clinician believes that areas of care SHOULD have been better.

Were there any areas of CONSIDERATION, of CONCERN or ADVERSE EVENTSin the management of this patient? Yes No

If NO areas of consideration etc., please go to Q22

If YES, please describe the 2 most significant events(over the page) and list any others

Yes No


PLEASE COMPLETE FOR ALL PATIENTS

PLEASE NOTE THE FOLLOWING DEFINITIONS

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 or to temporary or permanent impairment ordisability of the patient at the time of discharge, or which contributes to or causes death.

Have you reported these adverse events to IIMS? Yes No

Heparin or LMWH

Warfarin

Aspirin

Compression

TED Stockings

Other (specify)

Was death within 24 hours of last anaesthetic?

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SCF Version 1.9.2

Made no difference to outcomeMay have contributed to deathCaused death of patient whowould otherwise be expectedto survive

Area of: Which: Was it preventable?

21.2

Associated with?

21.3ANY OTHER AREAS OF CONCERN OR CONSIDERATION

ConsiderationConcern

DefinitelyProbablyProbably notDefinitely not

Audited Surgical teamAnother Clinical teamHospitalOther (Please specify)


21.1 (Please describe the most significant event):

Area of: Which:

Made no difference to outcomeMay have contributed to deathCaused death of patient whowould otherwise be expectedto survive

Was it preventable? Associated with?

ConsiderationConcern

DefinitelyProbablyProbably notDefinitely not

Audited Surgical teamAnother Clinical teamHospitalOther (Please specify)

Adverse Event

Adverse Event

22 Was there an unplanned return to theatre?Was there an unplanned admission to ICU?Was there an unplanned readmission within 30 days ofsurgery?Was fluid balance an issue in this case?Would it be beneficial for this case to undergo RootCause Analysis?

Yes No Don't Know

23 Hospital infectionYes No

Aquired infection before transfer?

Aquired infection after transfer?

Was this a surgical site infection?

Was hospital acquired infection MRSA+?

Did infection contribute to or cause death?

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SCF Version 1.9.2


24 In retrospect, would you have done anything differently?If Yes, please specify.

Yes No

Additional comments:

Page 7 of 7

THANK YOU


54128

FLA Version 1.3.2

Page 1 of 4

Study Number / /N SW 2 0

FLA Version 1.3.2

Page 1 of 4

Please return to:





PRIVILEGED

First Line Assessment Form




1323





FLA Version 1.3.2

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GUIDELINES FOR CHASM FIRST LINE ASSESSORS

Case Note Review A case note review is a peer assessment of the death of a patient. It should be carried out in a spirit of sympathetic enquiry and provide sufficient detail for a clear view of events. Points should be made in a detached manner and any opinions expressed should be objective and reasonable. There are advantages to a structured approach and the following guidelines address when to ask for a case note reviews and how the reviews should be carried out. When to ask for a Medical Case Note Review?

• Where significant errors are thought to have been made in the management of the patient.

• Where a case note review could usefully draw attention to lessons to be learned for the clinicians involved in the case.

• Where there has been an unexpected death (eg in theatre, elective surgery for benign disease, day case surgery, young patients)

• A case note review need not be requested if the adverse events are clear from the audit form and no further information is required

• Please indicate on the assessment form why a case note review is being requested

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FLA Version 1.3.2

Page 3 of 4

1. Was there enough information to come to a conclusion?If NO, what information was lacking?

Yes No

2. Should this case go for case notereview?If YES, which aspects of the case should be looked at in more detail? Yes No

3. If NO OPERATION was performed:Should an operation have been performed?If YES, what operation and why?

Yes No N/A

4. If an OPERATION WAS PERFORMED:Were there any Areas of Consideration, of Concern, or Adverse Events in any of the following areas(please refer to definitions overleaf and specify overleaf)

Pre-operative management/preparation

Yes No N/A

Decision to operate at all

Choice of operation

Timing of operation (too late, too soon, wrong time of day)

Intra-operative/technical management of surgery

Grade/experience of surgeon deciding


Post-operative care

5. Assessor's view (before any surgery) of overall risk of death


Was ICU used?Yes No N/A

If not, would the patient have benefited from ICU care?

Was HDU used?

If not, would the patient have benefited from HDU care?

Was the decision on the use of DVT prophylaxis appropriate?

Was fluid balance an issue in this case?


Would it be beneficial for this case to undergo Root Cause Analysis? Don'tKnow

PTO

6.


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FLA Version 1.3.2

Page 4 of 4

7.2

Area of:Consideration

Concern

Which:Made no difference to outcomeMay have contributed to deathCaused death of patient whowould otherwise be expected tosurvive

Was it preventable?DefinitelyProbablyProbably notDefinitely not

Associated with?Audited Surgical teamAnother Clinical teamHospitalOther (Please specify)

7.3

Area of:Consideration

Concern




Area of:ConsiderationConcern





If Areas of Consideration, of Concern, or Adverse Events have been identified, please list these in order ofsignificance and complete the details to allow accurate coding and feedback.

AREAS OF CONSIDERATION OF CONCERN OR ADVERSE EVENTS





An area for CONSIDERATION is where the clinician believes areas of care COULD have been IMPROVED orDIFFERENT, but recognises that it may be an area of debate.An area of CONCERN is where the clinician believes that areas of care SHOULD have been better.

7. Were there any areas of CONSIDERATION of CONCERN or ADVERSEEVENTS in the management of this patient? Yes No

FOR ALL CASES


Adverse Event

Adverse Event

Adverse Event

Adverse Event

THANK YOU

7.1

(please rank the most significant event(s))

7.44

(least significant)


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SLA Version 1.3.2

Page 1 of 5

Study Number / /N S W 2 0

SLA Version 1.3.2

Page 1 of 5

Please return to:





PRIVILEGED

Second Line Assessment Form




56593





SLA Version 1.3.2

Page 2 of 5


PTO

GUIDANCE FOR CHASM SECOND LINE ASSESSORS Case Note Review A case note review is a peer assessment of the death of a patient. It should be carried out in a spirit of sympathetic enquiry and provide sufficient detail for a clear view of events. Points should be made in a detached manner and any opinions expressed should be objective and reasonable. There are advantages to a structured approach and the following guidelines address when to ask for a case note reviews and how the reviews should be carried out. Tips on how to carry out a Medical Case Note Review

• Keep case notes safe and treat it with strict confidentiality • Identify time over the “next week” to do the case note review • Pay attention to: Clinical notes (Out Patients, ward, HDU/ICU); operation notes; discharge

summaries; nursing notes; integrated care pathways • Indicate the patient’s age group (eg young adult, middle aged, elderly) • Make all patients male • Omit identifying information eg names, specific dates and locations • Assess the case to determine if it adheres to a reasonable care pathway. If not, how does it

deviate and was it justifiable? • Specifically check the prescription of DVT/PE prophylaxis

Structure of a Second Line Assessment

• Aim for a case summary of no more than one page of A4 to include:

Background A sequence of events Learning points Areas of good practice, and Deficiencies of care (if any)

• Provide a short history and a factual account of the clinical events • Give constructive but not negative and critical comments on what could have been done

differently. Consider these questions: How have I phrased the report? Would I be upset if I received this review?

• Comment on the quality of the record keeping, e.g. if medical admission note is satisfactory/unsatisfactory or missing etc.

• Divide comments into "areas for consideration" (areas requiring further thought by the clinicians involved in the case, possibly reflecting alternative approaches in management) and "areas of concern" (management considered to be sub optimal, preferably supported by literature references). This should result in a focused assessment with graduated constructive comments.

• Suggest changes in practice that could be put in place to avoid repetition of identified adverse events in management, preferably with references.

• Complete the CHASM Second Line Assessment form Points to remember

• Note any areas for consideration, concern or adverse events to allow coding. • Where possible, give references to support your opinion.


56593

SLA Version 1.3.2

Page 3 of 5

Please complete this Form and attach a separate Case Report (go to page 5 of this document for blank page).The Case Report should be one A4 page long. Please provide a short history and factual account of clinical events.Do not include any identifying information (names, specific dates, locations). Indicate the patient's sex and age or agegroup. Give constructive comments on what could have been done differently. Suggest changes in practice that couldbe put in place to avoid repetition of identified adverse events or areas of concern. Please return this form withattached case report, the surgical case form and the case notes to CHASM in the express post envelope(s) provided.

First Line Assessor's comments/questions to be addressed by Second Line Assessor in Case Report

1. Record Keeping Satisfactory Unsatisfactory MissingMedical admission notesMedical follow up notesProcedure notesCase summary letter to GP

2. If NO OPERATION was performed:Should an operation have been performed? Yes No N/A

If YES, what operation and why?

3. If an OPERATION WAS PERFORMED:Were there any Areas of Consideration, of Concern, or Adverse Events in any of the following areas?(please refer to definitions overleaf and specify overleaf)

Pre-operative management/preparationDecision to operate at allChoice of operation

Intra-operative/technical management of surgeryGrade/experience of surgeon decidingGrade/experience of surgeon operatingPost-operative care

Yes No N/A

Timing of operation (too late, too soon, wrong time of day)

4. Assessor's view (before any surgery) of overall risk of death


Was ICU used?If not, would the patient have benefited from ICU care?

Yes No N/A

Was HDU used?If not, would the patient have benefited from HDU care?Was the decision on the use of DVT prophylaxis appropriate?Was fluid balance an issue in this case?


Would it be beneficial for this case to undergo Root Cause Analysis? Don'tKnow

PTO

5.


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SLA Version 1.3.2

Page 4 of 5

If Areas of Consideration, of Concern, or Adverse Events have been identified, please list these in order ofsignificance and complete the details to allow accurate coding and feedback.AREAS OF CONSIDERATION OF CONCERN OR ADVERSE EVENTS





6.2





6.3





6.4






An area of CONSIDERATION is where the clinician believes areas of care COULD have been IMPROVED orDIFFERENT, but recognises that it may be an area of debate.An area of CONCERN is where the clinician believes that areas of care SHOULD have been better.

6. Were there any areas of CONSIDERATION of CONCERN or ADVERSE EVENTS in the management of this patient? Yes No

FOR ALL CASES


(least significant)

Adverse Event

Adverse Event

Adverse Event

Adverse Event

6.1 (please rank the most significant event(s))

PTO


56593

SLA Version 1.3.2

Page 5 of 5

Medical Case Note ReviewThe Case Report should be one A4 page long and completed on this form. Please provide a short history and factualaccount of clinical events. Do not include any identifying information (names, specific dates, locations). Indicate the patient'ssex and age or age group. Give constructive comments on what could have been done differently. Suggest changes inpractice that could be put in place to avoid repetition of identified adverse events or areas of concern. Please return thisform with attached case report, the surgical case form and the case notes to CHASM in the express post envelope(s)provided.

THANK YOU


56593


ReferencesAmerican Society of Anesthesiologists, ASA Physical Status Classification System, viewed 10 February 2010, http://www.asahq.org/clinical/physicalstatus.htm

Cardiff Software Incorporated 2002, Getting started with Teleform, US Patents 4,893,333; 5,247,591; 5,555,101 and 5,943,137.

Cicchetti, DV & Feinstein, AR 1990, ‘High agreement but low kappa: II. Resolving the paradoxes’, Journal of Clinical Epidemiology, vol.43, no.6, pp. 551-558.

EPIC, Request information – READ codes, viewed 10 February 2010, http://www.epic-uk.org/read_codes.htm

Feinstein, AR & Cicchetti, DV 1990, ‘High agreement but low kappa: I. The problems of two paradoxes’, Journal of Clinical Epidemiology, vol.43, no.6, pp. 543-549.

NSW Injury Risk Management Research Centre 2004, Data confidentiality and privacy policy, IRMRC Privacy Policy, viewed 18.8.2010, http://www.irmrc.unsw.edu.au/documents/dataconfidentialityandprivacypolicy.pdf

Royal Australasian College of Surgeons 2011, Activities report for the period: 1 January - 31 December 2010, Royal Australasian College of Surgeons, viewed 11.2.2012, http://www.surgeons.org/media/306330/rpt2010_jan_to_dec_eoy_ar.pdf

Viera, AJ & Garrett, JM 2005, ‘Understanding interobserver agreement: the Kappa statistic’, Family Medicine, vol.37, no. 5, pp. 360-363, viewed 4 March 2010, http://www.stfm.org/fmhub/fm2005/May/Anthony360.pdf

http://www.asahq.org/clinical/physicalstatus.htm

http://www.epic-uk.org/read_codes.htm

http://www.irmrc.unsw.edu.au/documents/dataconfidentialityandprivacypolicy.pdf

http://www.surgeons.org/media/306330/rpt2010_jan_to_dec_eoy_ar.pdf

http://www.stfm.org/fmhub/fm2005/May/Anthony360.pdf

CONTACT DETAILS

Collaborating Hospitals’ Audit of Surgical Mortality

Office: Level 13, 227 Elizabeth St

Sydney NSW 2000

Post: CHASM


Locked Bag A4062

Sydney South NSW 1235

Telephone: 02 9269 5530

Fax: 02 9269 5599

Email: [email protected]

Web: www.cec.health.nsw.gov.au



http://www.cec.health.nsw.gov.au

cec's chasm program report july 2009-december 2010 · title: collaborating hospitals’ audit...

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