Lessons learned from VASM cases Barry Beiles Clinical Director VASM
Operative Mortality by specialty (n=5,184) Specialty Frequency (%) General surgery 2,073 (40.0%) Orthopaedic surgery 1,044 (20.1%) Neurosurgery 617 (11.9%) Cardiothoracic surgery 560 (10.8%) Vascular surgery 449 (8.7%) Urology 197 (3.8%) Plastic surgery 124 (2.4%) Otolaryngology head and neck surgery 56 (1.1%) Paediatric surgery 49 (0.9%) Obstetrics and gynaecology 9 (0.2%) Other surgeries 6 (0.1%) Total 5,184 (100.0%)
Victorian Admitted Episodes Database - VAED
Postoperative mortality rate - VAED
Number of audited deaths Mean age (range) Median age 2007-2015 n=6,179 74 years (0 day to 104 years) 79 years Gender (Male: Female) 55%: 45% Admission status (Emergency: Elective) 84%: 15% ASA grades ASA 1-2: 8% ASA 3: 27% ASA 4: 45% ASA 5-6: 15% Risk of death prior to surgery Expected: 13% Considerable: 50% Moderate: 25% Small: 9% Minimal: 3% Most common comorbid factors Cardiovascular: 23% Age: 19% Respiratory: 13% Renal: 10% Neurological/Psychiatric: 7% Diabetes: 6% Advanced Malignancy: 5% Obesity: 3% Hepatic: 3% Most common surgical diagnoses Fracture of neck of femur: 19% Carcinoma: 13% Intracranial haemorrhage: 11% Coronary artery disease: 7% Intestinal obstruction: 6% Aortic aneurysm: 5% Operative procedures performed 3: 9% 2: 16% 1: 75% 0: 16%
Thromboprophylaxis 6.6% inappropriately withheld
Critical care provision Only 8% would have benefited
Fluid management issues
Trends in clinical management issues over time
Top 5 management issues over time
Significance of clinical management issues Perceived impact on patient outcome Total occurrences Patients affected by (n=8431 in 6,179 cases) Clinical issues(n=6,179) No issues of management identified 3,204 4046 (65.4%) Did not affect clinical outcome 801 489 (7.9%) May have contributed to death 2,186 1251 (20.2%) Probably contributed to death 305 316 (5.1%) Missing data 163 77 (1.3%) Total 6,659 6179 (100%) Perceived preventability of clinical issues Total occurrences (n=8431 in 6,179 cases) Patients affected by Clinical issues(n=6,179) No issues identified 3,204 4046 (65.4%) Definitely preventable 403 379 (6.1%) Probably preventable 1,387 795 (12.9%) Probably not preventable 1,197 732 (11.8%) Definitely not preventable 119 96 (1.6%) Missing data 349 131 (2.2%) Total 6,659 6179 (100%) 19% of patients had significant preventable issues, which contributed to the death in 5%
Preventable deaths in VASM VSCC question at the end is unique to VASM Assessment Type Preventable Non-Preventable Percentage First-Line Assessment 365 4,690 7.2% Second-Line Assessment 531 569 48.3% TOTAL 896 5,259 14.6%
Recurring issues in 6,212 operative VASM cohort (85%) 2007-2016 Operative management issues Delays Recognition and management of the deteriorating patient Communication and shared care
1. Operative management issues No op should have been performed-futile surgery, end of life care A different op should have been performedseniority, choice by surgeon Technical issues in performance of surgery
Intraoperative issues FLA 2007-June 2016 Ops 6,212 Ops with CMI 2,171 Intraop Rx could be improved 708 No op should have been done 65 (9.2%)
Intraoperative issues FLA 2007-June 2016 Ops 6,212 Ops with CMI 2,171 Intraop Rx could be improved 708 Different op should have been done 138(19.5%)
Intraoperative issues FLA 2007-June 2016 Ops 6,212 Ops with CMI 2,171 Intraop Rx could be improved 708 Technical problem (haem, injury, leak) 117(16.5%)
2. Delays Delay in diagnosis 8 % Delay in starting treatment - 2%, surgeon, 3% FLA, 13% SLA Delay in transfer - 2%
Delay in 588/6,212(9.5%) of patients having an operation
Reasons for delay in diagnosis 2015 VASM report
Inter-hospital transfer issues 2015 VASM report
3. The deteriorating patient Failure to recognize Failure to react Junior staff education NB. Timing (out of hours) Location
4. Communication NB in the deteriorating patient-reluctance to contact superiors Inter-specialty referral should be timely and response should be rapid Documentation poor-poor or illegible data entry by clinicians, especially lack of consultant record entry
Conclusion VASM can identify factors contributing to surgical mortality Recurring themes must focus attention on prevention through better educational tools Continual expansion of the scope of ASM (anaesthetists, radiologists) and a shift in the role of this audit to better identify hospital outliers is a future goal that will be expected by our funder (DHHS)