Surgical Patient Deterioration - clinical outcomes audit

Peter L. Field, FRACS

Chairman, Victorian Surgical Consultative Council, Vascular Surgeon - Royal Melbourne

& Epworth Hospitals

Victorian audits of surgical care

The Victorian Surgical Consultative Council

• a clinical council within the Department of Health

• experienced surgeons of each specialty

• audits surgical care and morbidity in Victorian hospitals, adverse events, near-misses, sentinel events, avoidable deaths, hospital

complication rates

• advises surgeons, trainees, hospital CEOs, quality officers,

and nurse educators

The VSCC Intern Manual - Immediate Management of Surgical Emergencies

Victorian audits of surgical care

The Victorian Audit of Surgical Mortality (VASM)

• conducts the Department of Health surgical mortality registry

• VASM aligns with other State, Territory and NZ audits (ANZASM)

• Royal Australasian College of Surgeons mandates audit participation

• deaths under surgical care in all Victorian public and private hospitals, are notified by treating surgeon, and assessed by peer surgeons of the

same specialty

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• the audit loop: feedback to the treating surgeon and unit, plus reports and case reviews to all surgeons, trainees, hospital CEOs, Directors of

Surgery, quality & safety officers

VASM Case Note Review Booklet

The Victorian Surgical Consultative Council

Recent pitfalls and remedies:

• wrong side/site - “Time Out” ….. *Team

• laparoscopic vessel / bowel injury ….. *Surgeon

• retained gauzes or instruments …..*Team

• delayed recognition of complications ….. *Team

• deteriorating obs unrecognised ….. *Team

The Victorian Surgical Consultative Council

Surgical patient deterioration is hazardous:

• preoperatively (timely delivery of emergencies to operating theatre)

• in postoperative ward (structured handovers, accessible postop orders)

The Victorian Surgical Consultative Council

High-risk situations for surgical patients:

• patient transfers and handovers

• after hours and emergency procedures

• obese or co-morbid patients

• multiple consultants, unfamiliar wards

• carer fatigue, distraction, illness

• unsupervised trainees

• new staff, equipment or techniques

De-identified Hospitals Performance Comparison

Clinical outcomes of selected operations are studied by our Surgical Outcomes Initiative, using admitted episode coding data. The news is good - Victoria’s

outcomes are generally at a world high standard.

Victorian Hospitals sample outcome data (2yrs):

13,628 hysterectomies, 99.956% survival

1,953 laparoscopic hysterectomies, no death

59 haemorrhages, 106 organ injuries

237 oesophagectomies, 98.7% survival

22,907 inguinal hernia repairs, 99.930% survival

4,829 laparoscopic repairs, no death

7.6% were recurrent inguinal hernias 15 of the 16 deaths were emergency admissions (strangulated hernias)

The Victorian Surgical Consultative Council

Necessary clinician behaviour:

• be fit for task, rested, alert, healthy

• play the team game, hand-over well

• use good manners, communicate well

• call for help early

• write clear notes & postop orders:

V. H. universal postop orders checklist

The VSCC Victorian Hospitals Universal post-operative orders checklist

The Victorian Surgical Consultative Council

Universal post-operative orders checklist

• prompts the writer about obs, meds, drains

• accessible to ward staff during the admission

• avoids inadvertent omission of vital orders

• tailored to individual patient/procedure

• specific surgeon/anaesthetist expectations

• adopted in most Victorian surgical hospitals

The Victorian Surgical Consultative Council

Conclusions

• surgical patients may deteriorate at any time

• prompt recognition and response is vital

• auditing one’s own care is obligatory

• good note-keeping focuses the mind

• good manners achieve great teamwork

• vigilance and early escalation are effective

Surgical Patient Deterioration – importance of clinical outcomes audit

Peter L. Field, FRACS

Chairman, Victorian Surgical Consultative Council, Vascular Surgeon - Royal Melbourne

& Epworth Hospitals