The press release from the Australasian College of Surgeons late last year created curiosity. It said the 2017 report of the Western Australian Audit of Surgical Mortality showed a further small decline in mortality in patients under a WA surgeon.
The audit, performed by peers external to the hospital where the surgeon works, is funded by the WA Department of Health and is aimed at the ongoing improvement of surgical care. What did we know of the audit?
Western Australian surgical mortality audit
It was a transplant of the Scottish system (now no more) by Perth general surgeon Mr James Aitken in 2001 when he moved from Edinburgh to Perth. Despite the protection afforded to participants by legal privilege, participation rates were low until it was mandated as a condition of CPD points (participation is now 99.2%). In about 2010 the audit became national. Total deaths in WA are low – 22.1 per 100,000 population in 2016.
We spoke to Mr James Aitken, current chairman of the committee that reported.
“We are now able to access high quality information and data which was non-existent before this process begun. This provides us with an honest appraisal of where we are at as a profession and guides us in any education and training activities that may be required.”
“Although an important driver to compliance has been the College, making participation a compulsory component of CPD, surgeons acknowledge it changes their personal practice. Surveys done in WA, Queensland and Victoria all show this. The single most useful feedback is the Case Note Reviews and especially the Case Note Review booklets that group 10-15 cases.”
But how independent are the case reviews?
“An airline cannot investigate serious accidents any more than a construction or mining company can – by statute they have to call in Worksafe or an equivalent. Yet a hospital can undertake an RCA with no external input and investigate itself, often finding ‘no fault’ when WAASM has notified the hospital because the external peer reviewer felt there was fault. A simple, easy and relatively cheap initiative in WA hospitals would be that all RCAs or SCA 1 (Severity Assessment Code 1) include the involvement of a person from outside the hospital.”
Is it fear of speaking up, we asked. After all, our straw poll of GPs and Specialists in July last year showed that nearly all felt that not enough was done to protect whistleblowers.
“WAASM operates under Qualified Privilege and this protection permits surgeons to provide very detailed and honest reports and this includes acknowledging where care could have been different. Personally, I have never felt threatened when approaching either hospitals or the Department of Health with related issues.”
Emergency Laparotomies audit
In a separate but related project, James led a prospective WA audit looking at outcomes-related Emergency Laparotomies.
“Outcomes following Emergency Laparotomy have been known to be poor for many years with an overall mortality of 15%, and in those over 80 years, between 25% and 40%. Between 2010 and 2012, prospective overseas studies drew attention to just how bad the outcomes were and that compliance with evidence-based care standards was poor, even very poor.”
“This prompted the UK government to set up the National Emergency Laparotomy Audit (NELA) in England and Wales. which has just published its third report. Education and Quality Improvement have been key components and outcome and care standards are improving.”
“In the absence of any Australian data, the WA General Surgeons undertook the Perth Emergency Laparotomy Audit (PELA) in the second half of 2016. It showed a low mortality compared with overseas but poor compliance with evidence-based care standards.”
“PELA results were presented nationally in May and June 2017 and have caught the imagination.” This was partly because Australia had no fast-track pathway for patients presenting with an acute abdomen, according to ‘Perspective’ in the MJA last November.
“The RACS and ANZCA are in the advanced stages of planning the Australian and NZ Emergency Laparotomy Audit – Quality Improvement (ANZELA-QI). It should start mid-2018. So like WAASM, an audit that started in WA is going to become (hopefully) bi-national. The Quality Improvement is an important advance”
“The only missing ingredient is seed funding to establish ‘proof of concept’. We estimate the set up costs and three years of funding will be AU$1m and each day of reduced length of stay is worth about AU$34m per year (the NELA reduced hospital length of stay by 2.6 days). So the return on investment or ROI is massive”
James has been involved with the surgical audit for over 20 years – what has it taught him about human nature and the personalities you deal with? He points to a number of issues.
“Most clinicians have little knowledge of what they do or their results and no knowledge as to how that compares with others. Even the return of simple objective outcomes (death, unplanned re-admission, returns to theatre or ICU) has been shown to influence change.”
He feels that in this regard Australia is over 10 years behind the UK, this being because of a lack of political interest in audit and a failure of hospitals to tackle issues that are often well known.
“The reality is most ‘problems’ are well known (think Bundaberg) and the reason they persisted was because nobody did anything. We do not want ‘a Bristol’ to change this.”
Meeting community expectations
In this respect he thinks the community has failed itself.
“There is overwhelming evidence that the public and patients want better data but politicians and hospitals fail to provide it. So vote in politicians and go to hospitals which will provide it!”
He turns to the UK Minister of Health and his comment that ‘For data on surgical outcomes to be published, of course, they need to be robust, rigorous and risk adjusted’.
“The UK has done this and outcomes for named hospitals and surgeons have been available on many websites for over 10 years. There is none in Australia.”
Surgical antimicrobial prophylaxis
As if to flag the new transparency and accountability of Australian surgeons, an examination of surgical antimicrobial prophylaxis arrived from the Australian Prescriber about a month later.
With surgical antimicrobial prophylaxis the most common indication for antimicrobial use in Australian hospitals, surgeons have a big role to play in how appropriate that use is. With antibiotic resistance closing whole hospital wards, antibiotic stewardship has assumed greater importance both in this problem and in preventing adverse drug reactions.
The report says we need to improve the quality of surgical antimicrobial prophylaxis prescribing and points to overuse, especially minor procedures, and the use of ‘rarely indicated yet frequently prescribed’ topical antimicrobials.
The report says the Therapeutic Guidelines: Antibiotics is a key reference yet 40% of prescriptions were found to be inappropriate in the 2015 National Antimicrobial Prescribing Survey (22,021 prescriptions analysed from 281 hospitals).
Antimicrobial stewardship since 2011 has been one of the compulsory criteria for hospital accreditation and hospitals have been required to monitor antimicrobial use and resistance since 2014.
“The 2016 Surgical National Antimicrobial Prescribing Survey solely focuses on surgical prophylaxis prescribing. Its results highlight ongoing concerns regarding inappropriate prescribing (about 45%) in Australian hospitals. Where they were available, 41% of procedural and 62% of post-procedural prophylaxis was non-concordant with clinical guidelines…and antimicrobial prophylaxis was prescribed but not indicated in 40% of post procedural prophylaxis.”
The report says that appropriate surgical antimicrobial prophylaxis prescribing has these key elements: correct indication (not in clean non-prosthetic procedures), right antimicrobial chosen (look at microflora expected and patient-specific risk factors), drug dose (usually a single dose best), route (non-topical, usually parenteral), timing of administration and duration (usually within 60 minutes of incision).
The 2016 Prescribing Survey found that incorrect duration was the most common factor in inappropriate post-procedural antimicrobial prescribing (73.7%). Prophylaxis should not extend beyond 24 hours, regardless of the surgical procedure. Intravenous and oral antibiotic prophylaxis offered no benefit beyond this period.