Anaesthetic & Surgical Mortality Audits 
CLINICAL EXCELLENCE COMMISSION 
Prof Clifford Hughes AO 
26 August 2014
Mortality Audits 
Statutory expert committees empowered with special privileged information: 
•Special Committee Investiga...
History of SCIDUA 
•Setup in 1960 by Ministerial recommendation, approved by Cabinet. 
•First meeting 15thJuly 1960 
•1980...
Goals of SCIDUA 
•To review all patient deaths in NSW which occur under, prior to complete recovery from anaesthesia or se...
Membership of SCIDUA 
Representatives from: 
•Australian & New Zealand College of Anaesthetists 
•Australian Society of An...
Data collection for SCIDUA 
S84 of Public Health Act 2010 
Notification of deaths arising after anaesthesia or sedation fo...
SCIDUA Audit Processes 
•Notification of death 
•Triage: Did patient recover from anaesthesia? Was there an obvious non-an...
SCIDUA Classification of Deaths 
Modified from Edwards et al, 1956 and adopted by the Australian National Anaesthetic Mort...
SCIDUA Publications 
•Annual reports to the Minister 
•Contributes to triennial national reporting on safety of anaesthesi...
Estimated Anaesthetic Mortality Per Administration 
10 
NSW 
National 
1960 
1:5,500–1:8,000 
1970 
1:10,250 
1984-1990 
1...
Safety of Anaesthesia 
11 
1960-68 
2004-12 
Maternal deaths 
22 (7%) 
0 
Patientsunder 40 years 
93 (33%) 
17 (5%) 
Patie...
Preamble of CHASM 
•More than 20 years of experience in reviewing surgical mortality 
•Formerly known as the NSW Special C...
Purpose of CHASM 
•Confidential peer review of deaths which occur under the care of a surgeon 
•Facilitate reflective lear...
CHASM & RACS 
•Audit participation is mandatory to satisfy the RACS CPD program 
•NSW State Committee Chair is Deputy Chai...
CHASM & RACS 
•Audit participation is mandatory to satisfy the RACS CPD program 
•NSW State Committee Chair is Deputy Chai...
Governance of CHASM 
16 
Anaesthetic & Surgical Mortality Audits –August 2014 
Prof Clifford Hughes AO
CHASM Methodology 
•Notification of deaths from local health districts 
Patient was under the care of a surgeon or had si...
Potential Deficiency of Care: ACON 
•Area for consideration 
where the clinician believes care could have been improved or...
CHASM Feedback & Reports 
19 
Anaesthetic & Surgical Mortality Audits –August 2014 
Prof Clifford Hughes AO 
•Confidential...
CHASM Outputs 
20 
Anaesthetic & Surgical Mortality Audits –August 2014 
Prof Clifford Hughes AO 
2014 
2013 
1 Jan 2008 t...
CHASM Quality & Safety Indicators 
Tracks 13 surgical indicators: 
21 
Anaesthetic & Surgical Mortality Audits –August 201...
Improvement in VTE Prophylaxis 
22 
Anaesthetic & Surgical Mortality Audits –August 2014 
Prof Clifford Hughes AO 
Proport...
Improvement in Surgeons in Theatre 
23 
Anaesthetic & Surgical Mortality Audits –August 2014 
Prof Clifford Hughes AO 
Pro...
Improvement in Post-op Complications 
24 
Anaesthetic & Surgical Mortality Audits –August 2014 
Prof Clifford Hughes AO 
P...
Improvement in Surgical Site Infection 
25 
Anaesthetic & Surgical Mortality Audits –August 2014 
Prof Clifford Hughes AO ...
Improvement in ACON 
26 
Anaesthetic & Surgical Mortality Audits –August 2014 
Prof Clifford Hughes AO 
Proportion of audi...
Thank youQuestions 
PRESENTATION NAME – MONTH YYYY 
PRESENTER NAME 
27 
For further information: 
chasm@cec.health.nsw.gov...
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Prof Clifford Hughes - Clinical Exellence Commission - OPENING KEYNOTE ADDRESS | Mortality Audit: An Evidence Base to Drive Quality and Safety Improvement in Healthcare

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Prof Clifford Hughes delivered the presentation at the 2014 Clinical Audit Improvement Conference.

The Clinical Audit Improvement Conference explored the role of clinical audit in the new era of National Care Standards.

For more information about the event, please visit: http://bit.ly/clinicalaudit14

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Prof Clifford Hughes - Clinical Exellence Commission - OPENING KEYNOTE ADDRESS | Mortality Audit: An Evidence Base to Drive Quality and Safety Improvement in Healthcare

  1. 1. Anaesthetic & Surgical Mortality Audits CLINICAL EXCELLENCE COMMISSION Prof Clifford Hughes AO 26 August 2014
  2. 2. Mortality Audits Statutory expert committees empowered with special privileged information: •Special Committee Investigating Deaths Under Anaesthesia (SCIDUA) •Collaborating Hospitals’ Audit of Surgical Mortality (CHASM) Anaesthetic & Surgical Mortality Audits – August 2014 Prof Clifford Hughes AO 2
  3. 3. History of SCIDUA •Setup in 1960 by Ministerial recommendation, approved by Cabinet. •First meeting 15thJuly 1960 •1980 Activities suspended due to changes to the Coroner’s Act and confidentiality issues •1983 Reconstituted as Statutory Committee under Section 23 of the Health Administration Act •2004 Incorporation into Clinical Excellence Commission 3 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO
  4. 4. Goals of SCIDUA •To review all patient deaths in NSW which occur under, prior to complete recovery from anaesthesia or sedation, or which arise from any incident occurring during anaesthesia or sedation. •Identify correctable factors Anaesthetic & Surgical Mortality Audits – August 2014 Prof Clifford Hughes AO 4
  5. 5. Membership of SCIDUA Representatives from: •Australian & New Zealand College of Anaesthetists •Australian Society of Anaesthetists •University departments of anaesthesia Anaesthetic & Surgical Mortality Audits – August 2014 Prof Clifford Hughes AO 5
  6. 6. Data collection for SCIDUA S84 of Public Health Act 2010 Notification of deaths arising after anaesthesia or sedation for operations or procedures “….. a patient or former patient dies while under, or as a result of, or within 24 hours after, the administration of an anaesthetic or a sedative drug administered in the course of a medical, surgical or dental operation or procedure or other health operation or procedure (other than a local anaesthetic or sedative drug administered solely for the purpose of facilitating a procedure for resuscitation from apparent or impending death).” Anaesthetic & Surgical Mortality Audits – August 2014 Prof Clifford Hughes AO
  7. 7. SCIDUA Audit Processes •Notification of death •Triage: Did patient recover from anaesthesia? Was there an obvious non-anaestheticcause? •Questionnaire sent to Anaesthetist •Distribution de-identified case material to Committee members •Meeting and Classification •Letter to Anaesthetist •Analysis of data •Reports , publications and presentations 7 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO
  8. 8. SCIDUA Classification of Deaths Modified from Edwards et al, 1956 and adopted by the Australian National Anaesthetic Mortality Committee with further modifications •CATEGORY I, II & III Anaesthesiaplays all or some part in the fatality •CATEGORY IV, V & VI Anaesthesiaplayed no part (surgical/inevitable/fortutious) •CATEGORY VII & VIII No conclusion can be drawn from the data available 8 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO
  9. 9. SCIDUA Publications •Annual reports to the Minister •Contributes to triennial national reporting on safety of anaesthesia •Published papers on: Prevention of aspiration deaths Encouraged the use of vasopressors to treat hypotension rather than continued fluid loading in hip fracture surgery Highlighted fatal cardiovascular collapse with propofolin high risk patients 9 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO
  10. 10. Estimated Anaesthetic Mortality Per Administration 10 NSW National 1960 1:5,500–1:8,000 1970 1:10,250 1984-1990 1:20,000 1991-1993 1:55,000 1:68,000 1997-1999 1:38,000 1:79,500 2006-2010 1:32,600 These figures should be interpreted cautiously due to the different methodologies used in estimating the total number of anaesthetics administered. More accurate data on anaesthesia administration were reported by the Australian Institute of Health and Welfare in recent years. Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO
  11. 11. Safety of Anaesthesia 11 1960-68 2004-12 Maternal deaths 22 (7%) 0 Patientsunder 40 years 93 (33%) 17 (5%) Patients who were “fit and well” 50 (17%) 18 (6%) Orthopaedicdeaths 0 155 (48%) Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO “Fit and well” refers to patients who were assessed to have an ASA Grade of 1 or 2.
  12. 12. Preamble of CHASM •More than 20 years of experience in reviewing surgical mortality •Formerly known as the NSW Special Committee Investigating Deaths Associated With Surgery •Renamed as the Collaborating Hospitals’ Audit of Surgical Mortality (CHASM) in November 2007 •Adopted the audit methodology developed by the Scottish surgeons for SASM 12 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO
  13. 13. Purpose of CHASM •Confidential peer review of deaths which occur under the care of a surgeon •Facilitate reflective learning for surgeons •Identify potentially preventable deficiencies of care •Provide data to inform quality and safety initiatives •National audit (ANZASM) 13 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO
  14. 14. CHASM & RACS •Audit participation is mandatory to satisfy the RACS CPD program •NSW State Committee Chair is Deputy Chair of CHASM •CHASM provides annual de-identified audit data to ANZASM (administered by RACS) for national reporting of surgical mortality 14 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO
  15. 15. CHASM & RACS •Audit participation is mandatory to satisfy the RACS CPD program •NSW State Committee Chair is Deputy Chair of CHASM •CHASM provides annual de-identified audit data to ANZASM (administered by RACS) for national reporting of surgical mortality 15 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO
  16. 16. Governance of CHASM 16 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO
  17. 17. CHASM Methodology •Notification of deaths from local health districts Patient was under the care of a surgeon or had significant input to care Patient died within 30 days of an operation or during the last hospital admission +/-an operation •Surgical Case Form completed by the surgeon •First line assessment Secretariat removes all patient, hospital and surgeon identifiers Peer assessor is selected from the same surgical specialty, but from a different LHD •Second line assessment (case notes review) Approx15% Indications: -In cases where there is insufficient detail -Potential deficiency of care has been identified Anonymity is no longer possible 17 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO
  18. 18. Potential Deficiency of Care: ACON •Area for consideration where the clinician believes care could have been improved or beendifferent, but recognises that there may be debate. •Area of concern where the clinician believes that 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. 18 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO
  19. 19. CHASM Feedback & Reports 19 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO •Confidential feedback to reporting surgeon(s) on each audited death •Confidential individualised annual summary report to surgeons -with comparison to peer specialty group and all NSW participating surgeons •Case book with a key theme on: -aspiration pneumonitis -venous thromboembolism -recognition and management of deteriorating patients -clinical leadership -recognition of postoperative abdominal complications •Annual report -Data reported by surgical speciality, LHD & NSW -Individual Reports to LHDs -De-identified aggregated data for surgical indicators. -Specialties are not identified
  20. 20. CHASM Outputs 20 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO 2014 2013 1 Jan 2008 to 31 July 2014 No. of recorded deaths 1,340 1,916 13,341 No. (%) of deaths with completed surgical case forms 75 (57.8%) 1,387 (72.4%) 8,911 (66.8%) No. (%) of deaths with outstanding surgical case forms 394 (29.4%) 9 (0.5%) 403 (3.0%) No. (%) of deaths with non- participating surgeons* 171 (12.8%) 520 (27.1%) 4,027 (30.2%) No. (%) of deaths classified as terminal care 167 (21.5%**) 364 (26.2%**) 2,049 (23.0%**) No. (%) of deaths that have completed the audit at FLA 456 (58.8%**) 875 (63.1%**) 5,848 (65.6%**) No. (%) of deaths that have completed the audit at SLA 19 (2.5%**) 114 (8.2%**) 825 (9.3%**) No. (%) of deaths that have completed the audit 642 (82.8%**) 1,353 (97.5%**) 8,722 (97.9%**) *Non-participatingsurgeonsarethosewhohaveadvisedverballyorinwritingthattheydonotwishtoparticipateinCHASM.CHASMdoesnotsendasurgicalcaseformtothesesurgeons.Non-participatingsurgeonsalsorefertothosewhodonotreturnthesurgicalcaseformafterthreereminderletters. **Thedenominatorusedforcalculationofpercentageisthenumberofdeathswithcompletedsurgicalcaseforms.
  21. 21. CHASM Quality & Safety Indicators Tracks 13 surgical indicators: 21 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO •Pre-operative delay or error in confirmation of surgical diagnosis •Delay and/or problems with pre-operative transfer •Would have benefited from care at ICU or HDU •Appropriate use/non-use of prophylaxis against VTE •Elective surgery performed as planned •Consultant surgeon in theatre •Definable post-operative complications •Unplanned return to theatre •Unplanned admission to ICU •Unplanned hospital re- admission within 30 days of surgery •Issues with fluid balance •Surgical site infection •Potentially preventable deficiency of care identified by assessors
  22. 22. Improvement in VTE Prophylaxis 22 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO Proportion of audited deaths with appropriate use/non-use of prophylaxis against VTE, 2008 –2013 2008 2009 2010 2011 2012 2013 NSW(n=6076) 69% 76% 77% 79% 78% 78% 55% 60% 65% 70% 75% 80% 85% % of audited deaths Year of death Test for linear trend significant at p<0.0001, with χ² (df=1, n=6076)=26.05.
  23. 23. Improvement in Surgeons in Theatre 23 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO Proportion of audited deaths with consultant surgeon present in theatre, 2008 –2013 2008 2009 2010 2011 2012 2013 NSW (n=5335) 69% 67% 70% 70% 74% 73% 40% 50% 60% 70% 80% 90% 100% % of audited operative deaths Year of death Test for linear trend significant at p=0.0022, with χ² (df=1, n=5335)=9.39.
  24. 24. Improvement in Post-op Complications 24 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO Proportion of audited deaths with reported definable post- operative complications, 2008 –2013 2008 2009 2010 2011 2012 2013 NSW (n=5335) 42% 39% 37% 35% 35% 36% 0% 10% 20% 30% 40% 50% % of audited operative deaths Year of death Test for linear trend significant at p=0.0017, with χ² (df=1, n=5335)=9.83.
  25. 25. Improvement in Surgical Site Infection 25 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO Proportion of audited deaths with reported surgical site infection, 2008 –2013 2008 2009 2010 2011 2012 2013 NSW (n=5335) 8% 6% 5% 6% 6% 4% 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% % of audited operative deaths Year of death Test for linear trend significant at p=0.0083, with χ² (df=1, n=5335) = 6.98.
  26. 26. Improvement in ACON 26 Anaesthetic & Surgical Mortality Audits –August 2014 Prof Clifford Hughes AO Proportion of audited deaths with potentially preventable deficiency of care identified by assessors, 2008 –2013 Test for linear trend of all audited deaths significant at p=0.0003, with χ² (df=1, n=6076) = 13.2 2008 2009 2010 2011 2012 2013 NSW (n=6076) 15% 14% 16% 13% 11% 11% 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% % audited deaths Year of death
  27. 27. Thank youQuestions PRESENTATION NAME – MONTH YYYY PRESENTER NAME 27 For further information: chasm@cec.health.nsw.gov.au scidua@cec.health.nsw.gov.au www.cec.health.nsw.gov.au

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