Effective peer review audit and identification of the surgeon outlier.

BACKGROUND: Surgical audit aims to identify ways to maintain and improve the quality of care for patients, in part by assessment of a surgeon's activities and outcomes. However effective data systems to facilitate audit are uncommon. We aimed to assess the effectiveness of a tool for Peer Review Audit. METHODS: All General Surgeons in Darwin and the Top End were encouraged to self-record their surgical activity, including procedures and adverse events related to procedures, using the College's Morbidity Audit and Logbook Tool (MALT). RESULTS: A total of 6 surgeons and 3518 operative events were recorded in MALT between 2018 and 2019. De-identified reports of each surgeon's activities, compared directly to the audit group, were created by each surgeon, with correction for complexity of procedures and ASA status. Nine complications Grade 3 and greater were recorded, plus 6 deaths, 25 unplanned returns to theatre (8% failure to rescue rate), 7 unplanned admissions to ICU and 8 unplanned readmissions. One surgeon outlier was identified (>3 standard deviation over group mean) for unplanned returns to theatre. This surgeon's specific cases were reviewed at our morbidity and mortality meeting using the MALT Self Audit Report and changes were implemented as a result, with future progress monitored. CONCLUSION: The College's MALT system effectively enabled Peer Group Audit. All participating surgeons were readily able to present and validate their own results. A surgeon outlier was reliably identified. This led to effective practice change. The proportion of surgeons who participated was low. Adverse events were likely under-reported.

The associations of factors with previous alcohol use in the Northern Territory compared to other states - an observational study.

BACKGROUND: Data on previous alcohol use in surgical patients who died in the Northern Territory (NT) are lacking and have important public health implications. METHODS: The prevalence of previous alcohol (ab)use among surgical patients who died (n=560) was assessed in patients within the Northern Territory and the remainder of Australia (n=28,245) over nine years. RESULTS: The likelihood of previous alcohol use (21.4%; 120 of 560), was the outcome measured and was higher in the Northern Territory than outside it (5.9%; 1,660 of 28,245). Factors associated with the outcome of previous alcohol use were: male gender (aOR 1.6); Aboriginal and Torres Strait Islander status (aOR 2.0); liver disease (aOR 7.8); comorbidities (aOR 2.5); and trauma (aOR 1.1), in both the Northern Territory (aOR 11.5) and all Australia (aOR 7.8). In the Northern Territory, alcohol use was high in both Aboriginal and Torres Strait Islander people (31%) and non-Aboriginal and Torres Strait Islander (16%) people (p=0.316). CONCLUSION: Of surgical patients who died, the likelihood of being a previous alcohol user was double in the Northern Territory as opposed to other states. Alcohol misuse is widespread across all groups in the Northern Territory. Implications for public health: Previous alcohol (ab)use is a negative factor for survival in any racial group.

Early discharge of patients with acute pancreatitis to enhanced outpatient care.

BACKGROUND: Acute pancreatitis (AP) is a common cause for hospital admission, but some patients have a prolonged stay. The aim of this study was to identify patients with mild AP who had a prolonged hospital stay, who potentially could be discharged at day 2 to enhanced outpatient care. METHODS: Data was retrospectively collected on all patients admitted to the Royal Darwin Hospital between May 2016 and February 2017 with a diagnosis of mild AP to identify factors that may safely predict early discharge to enhanced outpatient care. RESULTS: Of 115 admissions, 62% were male, 50% indigenous and alcohol was causative in 53%. A total of 75 (65%) patients stayed more than 2 days and used 342 bed-days. Factors identified in the first 2 days of admission associated with a length of stay more than 2 days (R2 = 0.56, P < 0.0001) included pain score >5 (P = 0.034), temperature ≥38°C (P < 0.0001), white blood cell count >18 (P = 0.036), not tolerating oral diet by day 2 (P = 0.002), severe pancreatitis on imaging (P = 0.008) and readmission in the previous 30 days (P = 0.035). Using these criteria, 57% of all admissions and 87% of admissions greater than 2 days could potentially have been transferred to enhanced outpatient care at day 2 for management. This would have saved 277 inpatient bed-days and an estimated $122 771 over the 9-month study period. CONCLUSIONS: A significant proportion of patients admitted with mild AP, who stay longer than 2 days in hospital, could potentially be identified and discharged early to enhanced outpatient care.

Is Gastric Banding Appropriate in Indigenous Or Remote-Dwelling Persons?

BACKGROUND: Gastric banding has been promoted as less suitable for indigenous persons or persons who live remotely as it requires in person follow-up for band adjustment and may have higher rates of reoperation. This study assessed being an indigenous Australian or living remotely (but not both) on outcomes following gastric banding. METHODS: Data was prospectively recorded on all 559 patients who underwent gastric banding by one surgeon at one private hospital in Darwin, between February 1998 and August 2014. RESULTS: Forty persons (7 %) were indigenous and 93 (17 %) were remotely living (only 7 were both). At the last assessment (follow-up 37 (SD 31) months), overall percentage of excess weight loss (EWL) was 53 % (30 %), the percentage of total weight loss (TWL) was 23 (13), and 389 (70 %) achieved >50 % EWL. Seventy-two percent (43/60) ceased all diabetic medications. Ninety-two (17 %) came to reoperation. There was little difference between the indigenous and non-indigenous metropolitan-living groups, or between the remote and metropolitan non-indigenous groups in %EWL, %TWL, the proportion who achieved more than 50 % EWL, the time to achieve the goal weight, or cessation of diabetes medication. Similarly, there was little difference in the time to band removal or replacement. No person was directly compromised at band removal/replacement by delay due to dwelling remotely. CONCLUSIONS: In these select persons who underwent gastric banding in the private sector only, outcomes of weight loss and revisional surgery were acceptable and comparable between indigenous and non-indigenous metropolitan-dwelling persons as well as between remote and metropolitan-dwelling non-indigenous persons.

Emergency neurosurgery by general surgeons at a remote major hospital.

BACKGROUND: Due to the geographical remoteness of Darwin, which has no resident neurosurgeon, emergency transfer of patients for neurosurgery is usually impractical. In Darwin emergency neurosurgery must be undertaken by general surgeons. METHODS: Data from the operating theatre, Emergency Department and Intensive Care Unit were prospectively recorded on all patients who underwent an emergency neurosurgical procedure between January 1992 and June 2004. Outcomes were assessed by retrospective case note review. RESULTS: Three hundred and five neurosurgical procedures were performed upon 258 patients (average 26.5 procedures per year), including 130 craniotomies, 88 burr holes, 3 posterior fossa craniotomies, 2 decompressive frontal lobectomies, 4 decompressive craniectomies, 25 elevations of fracture and 33 ventricular drains only. Assault/domestic incident (31%) was a more common aetiology than motor vehicle accidents (29%). Outcome was best for extradural haematoma (82% good/moderate) and chronic subdural haematoma (84% good/moderate). In contrast, 44% with acute subdural haematoma and 77% with intracerebral haematoma died. Irrespective of type of bleed, Glasgow Coma Scale (GCS) score at presentation was a reliable predictor of outcome following surgery (61% correlation): 60% with GCS less than 9 died whereas 79% with GCS over 11 had a good recovery. Acute Physiology And Chronic Health Evaluation, version 2 and Simplified Acute Physiology Score, version 2 scores were also independent predictors of outcome. Time from presentation to operation for extradural haematoma and acute subdural haematoma was prolonged (more than 4 h) in 48% and was associated with worse outcome (P = 0.0001). Neither extremes of age nor the particular surgeon performing the operation affected outcome. CONCLUSIONS: General surgeons undertake a substantial number of procedures across a broad spectrum of emergency neurosurgery in Darwin. Outcomes following surgery appear acceptable.

Prediction of failure of native arteriovenous fistulas using 'on-line' fistula flow measurements.

BACKGROUND: Measurement of blood flow within native arteriovenous fistula during haemodialysis is recommended to detect incipient fistula failure. In the present study the value of such flow measurements was assessed in a group of patients on maintenance haemodialysis, with access via native arteriovenous fistulas. METHODS: Flow was measured using the 'on-line' thermodilution technique, on three separate occasions, and correlated with subsequent fistula failure within 6 months. RESULTS: Of the 53 patients studied, there were six failures (three thromboses and three inadequate dialysis filtration rates). Flow rates in patients who progressed to fistula failure were significantly less than flow rates in patients whose fistulas did not fail (U = 13.0, P < 0.0003). Failure was no more common in one type of fistula than another (type fistula: F = 0.29, P = 0.88; flow predicting failure: F = 7.22, P = 0.010). Receiver operating characteristic (ROC) curve analyses confirmed flow measurement to be a useful predictor of fistula failure (area under ROC curve 0.91). The optimal threshold of 576 mL/min flow gave a sensitivity of 89% and a specificity of 81%. Measurement of access resistance was less useful in predicting failure (area under ROC curve 0.87). Measurement of fall in flow from the previous measurement was of no use (area under ROC curve 0.535). CONCLUSION: On-line thermodilution measurement of flow within established native arteriovenous fistula is useful in surveillance and early prediction of fistula failure. Fistula flow <576 mL/min may indicate incipient native fistula failure, and should prompt further investigation.

Flipped out of control: single-vehicle rollover accidents in the Northern Territory.

OBJECTIVES: To study the incidence of and factors associated with single-vehicle rollover (SVRO) accidents in the "Top End" of the Northern Territory (NT); to identify factors associated with major injury and death from SVRO accidents. DESIGN: Retrospective analysis of records from the NT Department of Transport and Works' police database, Royal Darwin Hospital's trauma database, coroner's records, and case notes from public hospitals in the Top End. STUDY POPULATION: All patients involved in SVRO accidents in the Top End between 1 January 1996 and 31 December 1997 whose accident was documented by the police, who attended a public hospital, or who died. MAIN OUTCOME MEASURES: Types and incidence of all accidents; details of the accident scene, vehicle features, and population groups associated with SVRO accidents; factors associated with major injury and death. RESULTS: SVROs accounted for 30% of all accidents and 29% of all injuries and deaths (441 people) in the whole of the NT over the study period. Some of the factors associated significantly more frequently with SVRO accidents were (i) occurrence of the accident on a straight, dry, unsealed road; (ii) presence of a vehicle defect; (iii) travelling at excessive speed; and (iv) the person being male, aged 41-50 years, of Aboriginal descent. Among the 147 people who were admitted to hospital or died from SVRO accidents in the Top End, major injury occurred significantly more frequently if the person was under the influence of alcohol, was not wearing a seatbelt and was ejected; if the accident occurred in a rural area; and if the vehicle was speeding. Major injuries occurred in 21% (31/147), and death was more likely in those with head, chest and neck injuries. CONCLUSION: SVRO accidents are a major cause of morbidity and mortality in the Top End of the NT. Effective methods of limiting speeding, drink-driving and driver fatigue should be sought. Populations most at risk should be targeted.