Surgical interhospital transfer mortality: national analysis

Abstract

Background Interhospital transfers of surgical patients are an independent risk factor for mortality. The Australian and New Zealand Audit of Surgical Mortality (ANZASM) aims to improve surgical care through assessment of all cases of surgical mortality. This study aimed to describe common clinical management issues that contributed to interhospital transfer patient mortality. Methods Data for all surgical patient mortality in Australia (except New South Wales) that underwent interhospital transfer between 1 January 2010 and 31 December 2019 were extracted from ANZASM. The surgeons’ reports and assessors’ evaluations were examined to identify clinical management issues. Thematic analysis was performed to develop pertinent themes and subthemes. Results Some 8679 patients were identified over the 10-year period. Of these, 2171 (25.0 per cent) had 3259 clinical management issues identified. Prominent themes were operative design (n = 466, 14.3 per cent), decision to operate (n = 425, 13.0 per cent), medical conditions (n = 344, 10.6 per cent), diagnosis (n = 326, 10 per cent), transfer (n = 293, 10.0 per cent), intraoperative issues (n = 278, 8.5 per cent), inadequate assessment (n = 238, 7.3 per cent), communication (n = 224, 6.9 per cent), delay in recognizing complications (n = 180, 5.5 per cent), coagulopathy (n = 151, 4.6 per cent), insufficient monitoring (n = 127, 3.9 per cent), infection (n = 107, 3.3 per cent), and hospital resources (n = 100, 3.1 per cent). Assessors considered 58.4 per cent of clinical management issues (n = 1903) probably or definitely preventable. Conclusion This study identified 13 themes of potentially avoidable management issues present in surgical mortality following interhospital transfers. Quality-improvement initiatives targeting these areas may improve surgical patient outcomes.

Potentially avoidable mortality after endoscopic retrograde cholangiopancreatography in Australia: an 8‐year qualitative analysis

“…There were four clinical incidents where assessors noted inadequate fluid resuscitation, with responsibility attributed to the transferring hospital, 17,18 emergency department (ED) and in two cases the surgical team. In four cases, it was felt by assessors that the patient would have benefited from admission to the ICU, due to medical complexity and severity of disease.…”

“…In the second case the assessor commented that the patient would have benefited from a general anaesthetic (GA) rather than sedation, as it may have helped the patient tolerate the difficult therapeutic intervention, and potentially prevent the ensuing desaturation and collapse. It has been found that a GA is associated with reduced complications of therapeutic ERCP intervention when compared with conscious sedation, attributed to reduced movement and duodenal aperistalsis 17 . Thus in a patient with five large stones and one impacted in the proximal common bile duct, GA may have prevented the need for repeat ERCP.…”

“…While the treating doctor at the peripheral hospital should have commenced antibiotics immediately upon diagnosis of cholangitis, assessors felt this also 'should have been part of the phone discussion when arranging the transfer'. There were four clinical incidents where assessors noted inadequate fluid resuscitation, with responsibility attributed to the transferring hospital, 17,18 emergency department (ED) and in two cases the surgical team. In four cases, it was felt by assessors that the patient would have benefited from admission to the ICU, due to medical complexity and severity of disease.…”

“…It has been found that a GA is associated with reduced complications of therapeutic ERCP intervention when compared with conscious sedation, attributed to reduced movement and duodenal aperistalsis. 17 Thus in a patient with five large stones and one impacted in the proximal common bile duct, GA may have prevented the need for repeat ERCP. The third clinical incident related to inadequate equipment.…”

Implementation evaluation of tiered tele-triage pathways for burn center consultations and transfers

“…Finally, overnight referrals were also more likely to be assigned to the red pathway. Overnight referrals are variably described in the literature, but frequently attributed to referring hospital resource limitations 25,26 . For burn injuries requiring time- and resource-intensive care, referring providers may feel constrained when staffing is limited overnight.…”