Mortality in a University Surgical Unit: What is an Avoidable Death?

Mortality Pattern of Hospitalized Surgical Patients in a Nigerian Tertiary Hospital

There is paucity of reports describing the pattern of surgical mortality in Nigeria. The aim of this study was to determine the incidence and pattern of mortality associated with surgical care in our hospital and to identify areas of improvement. The records of all patients who died after admission for surgical care at the Federal Medical Centre Makurdi between January 2009 and December 2011 were studied retrospectively. Data extracted were patients' demographics, surgical diagnosis, co-morbidity, surgical procedures performed, duration of hospital admission and outcome of treatment. Data were analyzed with SPSS version 17. There were 2,273 admissions into the surgical wards within the study period. During this period, there were 151 deaths with a crude mortality rate of 6.6 %. Ninety-four (62.3 %) patients were males and 57 (37.7 %) were females (M:F = 1.6:1). The age of the patients ranged from 8 days to 95 years with a mean age of 36.1 ± 20.1 years. Acute abdomen (37, 24.5 %), traumatic brain injury (32, 21.2 %) and malignancy (28, 18.5 %) were the commonest surgical diagnosis. Trauma-related deaths accounted for 48 (31.8 %) of all the deaths. Road traffic crash (89.6 %) was the commonest cause of injury. Surgical operations were performed in 75 (49.7 %) of the patients who died, while 76 (50.3 %) did not have any operative intervention. Mortality in patients admitted into the surgical ward was 6.6 %. Trauma-related death was the commonest. Traumatic brain injury, typhoid perforation of the bowel and malignancy were the leading causes of surgical death in our centre.

Mortality pattern in the surgical wards: a five year review at Federal Medical Centre, Owerri, Nigeria

OBJECTIVE

To identify deaths in the surgical wards, elicit the cause of death and suggest changes that will ensure improved surgical care of patients and outcome.

STUDY DESIGN

Retrospective.

METHODS

Records collected from the theatre operation registers, ward registers and case notes of all patients who were admitted into the surgical wards Federal Medical Centre, Owerri whether elective or emergency from January 1997 to December 2001 were reviewed. Data extracted included date of admission, age, sex, educational status, residence; surgical diagnosis and clinical cause of death Data obtained were analyzed and presented in tabular and descriptive forms.

RESULTS

There were 4583 surgical admissions in all the surgical wards of which males were 2751 and females 1832. During this period there were 419 deaths with an overall death per admission crude mortality rate of 9.14%. The leading causes of death were acute abdomen (22.20%), RTA with head injury (18.14%) and malignances (14.56%). Of the 419 deaths males were 305 (72.79%) and females 114 (27.21%) in a ratio of 2.68:1.

CONCLUSION

Aggressive enlightenment and healthcare campaigns, health education, improvement of healthcare facilities and accessibility to healthcare facilities are highlighted. Structured study in the management of surgical cases is emphasized.

Elective resection and anastomosis for colorectal cancer: a prospective audit of mortality and morbidity 1976-1998

BACKGROUND

The purpose of this paper is to audit the morbidity and mortality for colorectal cancer after open elective resection and anastomosis by a single colorectal surgeon (MK), with reference to any differences between intraperitoneal (IPA) and extra-peritoneal anastomoses (EPA).

METHODS

The prospective documentation of postoperative complications was compiled by the surgeon, charge nurses and a research assistant (PB). The operations were performed in three hospitals between 1976 and 1998.

RESULTS

Some 1392 consecutive patients were treated electively by 1418 resections with anastomosis. There were 23 postoperative deaths (1.6%). Significant adverse events, which were potentially avoidable, occurred in 10 (43.5%) of the patients who died. The morbidity rate was 41.6%. Clinical anastomotic leaks occurred more frequently in EPA (27/581, 4.7%) than in IPA (2/827, 0.2%; P < 0.0001). Anastomotic leak caused the death of two patients (0.14%).Routine prophylactic anticoagulation did not decrease the incidence of pulmonary embolism. Significant thrombophlebitis at the intravenous cannula site occurred in 54 patients (3.8%), wound infection in 29 (2.1%), and postural peripheral nerve injury in the upper limbs occurred in 11 patients (0.8%). Thirty-eight patients (2.7%) were returned to the operating theatre for 42 unscheduled operations.

CONCLUSION

Mortality associated with elective resection of colorectal cancer with anastomosis is principally related to age, cardio-vascular disease and avoidable adverse events. A wide range of complications may follow this type of surgery, especially after extra peritoneal operations. A classification of anastomotic leaks is suggested to assist in comparisons of this complication which remains a significant concern following extra peritoneal anastomoses.

Mortality after appendectomy in Sweden, 1987-1996

OBJECTIVE

To study mortality after appendectomy.

SUMMARY BACKGROUND DATA

The management of patients with suspected appendicitis remains controversial, with advocates of early surgery as well as of expectant management. Mortality is not known.

METHODS

The authors conducted a complete follow-up of deaths within 30 days after all appendectomies in Sweden (population 8.9 million) during the years 1987 to 1996 (n = 117,424) by register linkage. The case fatality rate (CFR) and the standardized mortality ratio (SMR) were analyzed by discharge diagnosis.

RESULTS

The CFR was 2.44 per 1,000 appendectomies. It was strongly related to age (0.31 per 1,000 appendectomies at 0-9 years of age, decreasing to 0.07 at 20-29 years, and reaching 164 among nonagenarians) and diagnosis at surgery (0.8 per 1,000 appendectomies after nonperforated appendicitis, 5.1 after perforated appendicitis, 1.9 after appendectomies for nonsurgical abdominal pain, and 10.0 for those with other diagnoses). The SMR showed a sevenfold excess rate of deaths after appendectomy compared with the general population. The relation to age was less marked (SMR of 44.4 at 0-9 years, decreasing to 2.4 in patients aged 20-29 years. and reaching 8.1 in nonagenarians). The SMR was doubled after perforation compared with nonperforated appendicitis (6.5 and 3.5, respectively). Nonsurgical abdominal pain and other diagnoses were associated with a high excess rate of deaths (9.1 and 14.9, respectively). The most common causes of deaths were appendicitis, ischemic heart diseases and tumors, followed by gastrointestinal diseases.

CONCLUSIONS

The CFR after appendectomy is high in elderly patients. The excess rate of death for patients with nonperforated appendicitis and nonsurgical abdominal pain suggests that the deaths may partly be caused by the surgical trauma. Increased diagnostic efforts rather than urgent appendectomy are therefore warranted among frail patients with an equivocal diagnosis of appendicitis.

Studies of avoidable factors influencing death: a call for explicit criteria

OBJECTIVE

To analyse studies evaluating cases of potentially "avoidable" death.

DESIGN

The definitions, sources of information, and methods were reviewed with a structured protocol. The different types of avoidable factors,--that is, deficiencies in medical care that may have contributed to death--were categorised. The presence of explicit classifications and standards was examined. basic criteria for quality of the studies were defined and the numbers of studies fulfilling these criteria were assessed.

SETTING AND PARTICIPANTS

65 studies, published during 1988-93 in peer reviewed medical journal for which the title, or abstract, or both indicated that they had analysed potentially avoidable factors influencing death. Studies analysing aggregated data only, were not included.

RESULTS

Only one third of the studies fulfilled basic quality criteria,--namely, that the avoidable factors examined should be defined and the sources of information and people responsible for the judgements presented. The definitions used comprised two levels, one stating that there had been errors in management (process) and the other that the errors may have contributed to the deaths (outcome). Only 15% of the studies explicitly defined what type of factors they had looked for and 8% referred to specified standards of care.

CONCLUSIONS

Studies of avoidable factors influencing death may have considerable potential as part of a system of improving medical care and reducing avoidable mortality. At present, however, the results from different studies are not comparable, due to differences in materials and methods. There is a need to improve the quality of the studies and to define standardised explicit definitions and classifications.

Measuring the effects of casemix on outcomes

Participation in the measurement of population health and health care outcomes has become an explicit professional duty for doctors, but comparisons are difficult to make because outcomes are conceptually complex and largely qualitative. Observational data, particularly from routine hospital statistics, are useful complements to experimental data provided that their variable quality is taken into account and adjustments are made to minimize bias and confounding and to allow for the effects of differences in casemix, which are problematic because of the nature of severity.