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Peter Field presented this at the 2014 Managing the Deteriorating Patient Conference. The conference discussed the latest strategies to recognise and respond to the acute patient in clinical deterioration. You can find out more about next year's conference at http://bit.ly/1sjQubi
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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