SCOTTISH AUDIT OF SURGICAL MORTALITY
Scottish Audit of Surgical Mortality Annual Report 1999
Read the full SASM 1999 Annual Report
CONCLUSIONS
Patient transfer
There are infrequent but significant problems in this area. These encompass delay, difficulties during the journey and inappropriate transfer.
Peri-operative care
There was a reduction in the incidence of adverse events related to peri-operative management. However, this remains an area of concern, particularly with regard to the identification of the ill patient. Monitoring, including invasive monitoring, is under-used.
Grade of Staff
Despite the high level of consultant presence recorded in Scotland, there continues to be a small number of cases where assessors felt that trainees worked outwith their level of expertise without adequate direct supervision.
Critical Care
SASM continues to highlight problems with the provision and use of HDU and ICU. The Scottish Executive established a working party in the Summer of 2000 which has reported on this area.
Orthopaedics/Trauma
The grade of anaesthetist in ASA 3 and 4 orthopaedic cases is a particular cause for concern.
Audit
Based on our experience of the audit process since 1994, the marked variation in style and availability of case notes inhibits truly effective audit. Furthermore, it is impossible to put the data into full context without access to data on total activity (denominator and case-mix data).
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RECOMMENDATIONS
Patient transfer
There are accepted minimum standards for the transfer of critically ill patients. The safe transfer of patients is a vital component of any Managed Clinical Network. Trusts must ensure a satisfactory level of care through documented protocols and the provision of necessary resources, not by ad hoc arrangements. Each geographical area requires different solutions and the provision should be locally relevant with a full assessment of its impact. This will be the subject of further enquiry in a future audit cycle.
Peri-operative care
This is an area for consensus guidelines. A collaboration between SIGN (Scottish Intercollegiate Guideline Network) and SASM has begun to address this.
Whenever possible, peri-operative quantitative grading of the patient's physiological and pathological status, encompassing previous ill health, current condition and the nature of the operation, is recommended (e.g. POSSUM).
The early identification of the at risk patient is of prime importance. To facilitate this, serious consideration should be given to introducing tools such as early warning scoring systems on patient monitoring charts.
Grade of Staff
ASA 4 and 5 cases undergoing anaesthesia, must be discussed with a consultant anaesthetist.
Cases at 'considerable risk' of death undergoing an operation must be discussed with a consultant surgeon.
Critical Care
SASM welcomes the response of the Scottish Executive to previous annual reports. We commend the conclusions of the recent publication "Better Critical Care". It is likely that the perceived need for critical care beds will continue to outstrip provision and it is vital that clear admission and discharge protocols are established, used and audited.
Orthopaedics/Trauma
Daily dedicated trauma sessions, staffed by consultant surgeons and consultant anaesthetists, are urgently required.
Audit
There is a pressing need for a national approach to patient identifiers, operation notes and anaesthetic forms with the establishment of agreed main data sets within specialties. This in turn would begin to supply, along with the progression of the current collaboration between SASM and ISD (Information and Statistics Division of the Common Services Agency), reliable and clinically relevant denominator and case-mix data.
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