Medical versus surgical causes of death following colorectal resection: a Queensland Audit of Surgical Mortality (QASM) study.

BACKGROUND: The causes of death following colorectal resection remain poorly explored. Few studies have addressed whether early post-operative mortality is predominantly caused by a patient's medical co-morbidities, or from factors pertaining to the presenting surgical disease process itself. This study analyses data from the Queensland audit of surgical mortality (QASM) to report the causes of in-hospital death following colorectal resection, identifies whether these were due to either medical or surgical factors, and determines the patient characteristics associated with a medical cause of death. METHODS: Through analysis of QASM Surgical Case Forms, the causes of in-hospital death were determined in 750 patients who died in Queensland following colorectal resection between January 2010 and December 2020. Deaths were attributed to a specific medical or surgical cause, with multivariate analysis used to identify independent risk factors associated with a medical cause of death. RESULTS: In total, 395 patients (52.7%) died due to surgical causes and 355 (47.3%) died due to medical causes. Respiratory co-morbidities (OR 1.832, 95% CI: 1.267-2.650), advanced malignancy (OR 1.814, 95% CI: 1.262-2.607), neurological co-morbidities (OR 1.794, 95% CI: 1.168-2.757) and advanced age (OR 1.430, 95% CI: 1.013-2.017) were independent risk factors associated with increased risk of a medical cause of death. CONCLUSION: Even in the absence of complicating surgical factors, a significant number of patients died in hospital following colorectal resection due to their underlying co-morbidities. Multi-disciplinary models of care which allow for the early recognition and treatment of medical complications may reduce post-operative mortality in these patients.

Critical Analysis of the Causes of In-Hospital Mortality following Colorectal Resection: A Queensland Audit of Surgical Mortality (QASM) Registry Study.

BACKGROUND: Colorectal resection is a major gastrointestinal operation. Improvements in peri-operative care has led to improved outcomes; however, mortalities still occur. Using data from the Queensland Audit of Surgical Mortality (QASM), this study examines the demographic and clinical characteristics of patients who died in hospital following colorectal resection, and also reports the primary cause of death in this population. METHODS: Patients who died in hospital following colorectal resection in Queensland between January 2010 and December 2020 were identified from the QASM database. RESULTS: There were 755 patients who died in the 10 year study period. Pre-operatively, the risk of death as subjectively determined by operating surgeons was 'considerable' in 397 cases (53.0%) and 'expected' in 90 cases (12.0%). The patients had a mean of 2.7 (±1.5) co-morbidities, and a mean American Society of Anaesthesiologists (ASA) score of 3.6 (±0.8). Operations were categorised as emergency in 579 patients (77.2%), with 637 patients (85.0%) requiring post-operative Intensive Care Unit (ICU) support. The primary cause of death was related to a surgical cause in 395 patients (52.7%) and to a medical cause in 355 patients (47.3%). The primary causes of death were advanced surgical pathology (n=292, 38.9%), complications from surgery (n=103, 13.7%), complications arising from pre-existing medical co-morbidity (n=282, 37.6%) or new medical complications unrelated to pre-existing conditions (n=73, 9.7%). CONCLUSIONS: Patients who died had significant co-morbidities and often presented emergently with an advanced surgical pathology. Surgical and medical causes of death both contributed equally to the mortality burden.

Telehealth in surgery: an umbrella review.

BACKGROUND: Telehealth use has increased worldwide during the COVID-19 pandemic. However, hands-on requirements of surgical care may have resulted in slower implementation. This umbrella review (review of systematic reviews) evaluated the perceptions, safety and implementation of telehealth services in surgery, and telehealth usage in Australia between 2020 and 2021. METHODS: PubMed was searched from 2015 to 2021 for systematic reviews evaluating real-time telehealth modalities in surgery. Outcomes of interest were patient and provider satisfaction, safety, and barriers and facilitators associated with its use. Study quality was appraised using the AMSTAR 2 tool. A working group of surgeons provided insights into the clinical relevance to telehealth in surgical practice of the evidence collated. RESULTS: From 2025 identified studies, 17 were included, which were of low to moderate risk of bias. Patient and provider satisfaction with telehealth was high. Time savings, decreased healthcare resource use and lower costs were reported as key advantages of the service. Inability to perform comprehensive examinations was noted as the primary barrier. In Australia, peak telehealth usage coincided with the introduction of temporary telehealth services and increased lockdown measures. CONCLUSIONS: Patients and providers are broadly satisfied with telehealth and its benefits. Barriers may be overcome via multidisciplinary collaboration. Telehealth may benefit surgical care long-term if implemented correctly both during and after the COVID-19 pandemic.

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.

Surgeons' Responses to a Surgical Mortality Audit: Accepting and Improving: A Cross Sectional Survey.

BACKGROUND: Surgeons strive to provide the best care possible to their patients. The Australian and New Zealand Audit of Surgical Mortality is a process for improving surgical care and outcomes via peer-review assessment of mortality cases. This article examines the acceptability of the assessments to Queensland surgeons, in addition to examining their impact on surgical care. METHODS: This study was a cross-sectional survey. Evaluation forms were sent to all Queensland surgeons who had received a first-line assessment with clinical incidents identified or a second-line assessment (with or without clinical incidents), between April 2018 and January 2020 (n = 484). A total of 102 evaluation forms were returned, giving a response rate of 21%. RESULTS: Most respondents agreed that their assessments were fair (78%) and informative (69%). Almost half (43%) agreed that their assessment improved the subsequent surgical care they provided. Comments supported this, with surgeons describing reflections, meetings and changes that had occurred following their assessments. Despite the strong proportion of positive comments, some surgeons disagreed with the opinions or recommendations of their assessors. A large percentage (41%) was neutral towards the ability of the assessments they had received to improve surgical care at the hospital level. CONCLUSIONS: There was a high degree of acceptance of the QASM peer-review assessment process. The assessments facilitated discussion, reflection and implementation of surgical care improvements in Queensland surgeons. Further research into this topic should involve refinement of the study tool with a larger, and therefore more representative, proportion of the surgical population.

Variability in clinicians' understanding and reported methods of identifying high-risk surgical patients: a qualitative study.

BACKGROUND: High-risk patients presenting for surgery require complex decision-making and perioperative management. However, given there is no gold standard for identifying high-risk patients, doing so may be challenging for clinicians in practice. Before a gold standard can be established, the state of current practice must be determined. This study aimed to understand how working clinicians define and identify high-risk surgical patients. METHODS: Clinicians involved in the care of high-risk surgical patients at a public hospital in regional Australia were interviewed as part of an ongoing study evaluating a new shared decision-making process for high-risk patients. The new process, Patient-Centred Advanced Care Planning (PC-ACP) engages patients, families, and clinicians from all relevant specialties in shared decision-making in line with the patient's goals and values. The semi-structured interviews were conducted before the implementation of the new process and were coded using a modified form of the 'constant comparative method' to reveal key themes. Themes concerning patient risk, clinician's understanding of high risk, and methods for identifying high-risk surgical patients were extricated for close examination. RESULTS: Thirteen staff involved in high-risk surgery at the hospital at which PC-ACP was to be implemented were interviewed. Analysis revealed six sub-themes within the major theme of factors related to patient risk: (1) increase in high-risk patients, (2) recognising frailty, (3) risk-benefit balance, (4) suitability and readiness for surgery, (5) avoiding negative outcomes, and (6) methods in use for identifying high-risk patients. There was considerable variability in clinicians' methods of identifying high-risk patients and regarding their definition of high risk. This variability occurred even among clinicians within the same disciplines and specialties. CONCLUSIONS: Although clinicians were confident in their own ability to identify high-risk patients, they acknowledged limitations in recognising frail, high-risk patients and predicting and articulating possible outcomes when consenting these patients. Importantly, little consistency in clinicians' reported methods for identifying high-risk patients was found. Consensus regarding the definition of high-risk surgical patients is necessary to ensure rigorous decision-making.

Economic Advantages of Telehealth and Virtual Health Practitioners: Return on Investment Analysis.

BACKGROUND: Telehealth is a disruptive modality that challenges the traditional model of having a clinician or patient physically present for an appointment. The benefit is that it offers the opportunity to redesign the way services are offered. For instance, a virtual health practitioner can provide videoconference consultations while being located anywhere in the world that has internet. A virtual health practitioner also obviates the issues of attracting a specialist medical workforce to rural areas, and allows the rural health service to control the specialist services that they offer. OBJECTIVE: The aim of this research was to evaluate the economic effects of 3 different models of care on rural and metropolitan hospital sites. The models of care examined were patient travel, telehealth using videoconferencing, and employment of a virtual health practitioner by a rural site. METHODS: Using retrospective activity data for 3 years, a return on investment (ROI) analysis was undertaken from the perspective of a rural site and metropolitan partner site using a telehealth orthopedic fracture clinic as an example. Further analysis was conducted to calculate the number of patients that would be required to attend the clinic in each model of care for the sites to break even. RESULTS: The only service model that resulted in a positive ROI for the rural site over the 3-year period was the virtual health practitioner model. The breakeven analysis demonstrated that the rural site required the lowest number of patients to recoup costs in the virtual health practitioner model of care. The rural site was unable to recoup its costs within the travel model due to the lack of opportunity for reimbursement for services and the requirement to cover the cost of travel for patients. CONCLUSIONS: Our model demonstrated that rural health care providers can increase their ROI by employing a virtual health practitioner.

Quantifying the Impact of Excluding Insecticide Classes From Cotton Integrated Pest Management Programs in the U.S. Mid-South.

Current assessments from the U.S. Environmental Protection Agency suggest that some current insecticides may be lost or severely restricted in the near future. An experiment was conducted from 2014 to 2015 at two locations in Mississippi to determine the impact of losses of insecticide classes on integrated pest management of insect pests in cotton. The treatments included cotton treated with all available classes of insecticides, cotton treated with all classes except neonicotinoids, cotton treated with all classes except pyrethroids, cotton treated with all classes except carbamates and organophosphates, and an untreated control. Plots were scouted weekly and insecticide applications were made with the most efficacious and economical insecticides for each treatment when that treatment reached threshold for a particular insect pest(s). The primary insects at both locations were tobacco thrips and tarnished plant bugs. Thrips pressure was similar at both locations and generally showed that all insecticide treatments provided a similar level of protection compared with the untreated control. At the Stoneville location where tarnished plant bug pressure was greatest, cotton yields and economic returns differed between plots where all classes of insecticides were applied compared with the untreated control and where neonicotinoids were excluded. However, in Starkville where tarnished plant bug pressure was less, there were no differences among treatments. Although yield and economic returns were similar in high tarnished plant bug pressure areas when using all classes compared with managing without pyrethroids or organophosphates, a rotation among all insecticide classes should be beneficial for resistance management in Mid-South cotton production.

Post-mortem general surgeon reflection on decision-making: a mixed-methods study of mortality audit data.

BACKGROUND: Surgical deaths in Australia require the treating surgeon to document the event via a standard report. A section of this report invites surgeons to reflect on changes to management they would initiate in retrospect. This study analyses these reflective statements and categorizes them in an effort to gain insight into reflective learning. METHODS: This audit-based cross-sectional study involves patients who died in-hospital under the care of general surgeons in Queensland, Australia, between July 2007 and December 2016. Retrospective surgeon statements were analysed using both quantitative and qualitative methods. RESULTS: Of the 2575 surgeons, 459 (18%) indicated they would manage their patient differently in retrospect. Half of these statements (46%) concerned changes to an operative decision. Of this group, most of these concerned either the decision to operate or not (26%), what operation to perform (32%) or earlier timing of surgery (32%). Overall, one-third of statements (29%) concerned retrospective changes to clinical decisions not related to operative management. Communication considerations, ceiling of care decisions and technical operative changes made up smaller proportions of statements. CONCLUSION: This mixed-methods study has identified a minority of surgeons proffer retrospective management changes after their patient has died. Of those who do, decision-making around operative management is the most common area of reflective consideration.

Snapshot of trauma laparotomy deaths in Queensland.

BACKGROUND: Trauma remains the most frequent cause of death for patients under 35 years of age. Head injury and catastrophic haemorrhage account for the majority of early deaths. A trauma laparotomy is often necessary to arrest haemorrhage. METHODS: All patients who died in Queensland hospitals between 2011 and 2016 having had a trauma laparotomy were identified from the Queensland Audit of Surgical Mortality. RESULTS: About 69.0% of the 84 deaths were male with a median age of 47.6 years. About 64.3% of deaths occurred within the first 2 days following trauma. Mechanism of injury was typically road traffic accident (77.4%). Sixteen patients underwent a non-therapeutic laparotomy. Following peer-review, different management was recommended for only three patients. CONCLUSION: This group of patients who died in the setting of a trauma laparotomy received high quality trauma care. Ongoing education is needed as some non-therapeutic laparotomies may be avoidable.

Clavicle fracture management: A comparison of a tertiary hospital and rural telehealth sites.

The clavicle is one of the most commonly fractured bones in the adult population. Management has traditionally been conservative, however more recent research has yielded higher non-union rates associated with non-operative management. This study aims to analyse the proportion of operative and non-operative treatment methods for clavicle fracture in a tertiary hospital facility and rural health sites accessed via telehealth, comparing patient outcome between these two methods of fracture management. Following ethical approval, a retrospective review was conducted of patients presenting with clavicle fractures to the Princess Alexandra Hospital Fracture Clinics and to Orthopaedic Fracture Clinics run via teleconference with rural health sites. Only 2% of patients received operative fracture management in the telehealth group, versus 33% in the tertiary hospital sample. Patient outcome was measured in the larger tertiary hospital sample, with clinical notes reflecting good patient outcome in 70% of operatively managed patients and 85% of patients with conservatively managed clavicle fractures. For the patients in the telehealth sample that returned for follow-up appointments, 93% reported a good outcome with one of these individuals undergoing operative treatment and the rest managed conservatively.

Tele-orthopaedics: A snapshot of services in Australia.

Health services in the United States and Europe have reported that tele-orthopaedics saves significant patient travel time, reduces time off work, increases satisfaction with care and in some scenarios reduces the cost of care. Less is known about the role of tele-orthopaedics in Australia. The aim of this study was to explore Australian-based tele-orthopaedic services, and to identify the barriers and enablers associated with these services. We used a qualitative case study methodology where specific services were identified from multiple sources and invited to participate in a structured interview. Nine tele-orthopaedic services contributed to the study. Telehealth activity in each service ranged from one to 75 patients per week, and service maturity ranged from three months to 10 years. Services were used predominantly for fracture clinics and peri-operative consultations. The majority (78%) of services used videoconferencing. Two services used asynchronous methods to review radiographs without direct patient involvement. Tele-orthopaedics was found to be disruptive as it required the redesign of many care processes. However, all services found the redesign feasible. Staff resistance was a commonly cited barrier. Further, imaging repositories from multiple imaging providers complicated access to information. Key enablers included clinical champions, picture archiving and communication systems, and the perceived benefit to patients who would avoid the need for travel. Whilst it appears that tele-orthopaedics is not widely utilised in Australia, recognition of the barriers and enablers is important for the development of similar services.

How participation in surgical mortality audit impacts surgical practice.

BACKGROUND: Surgical mortality audit is an important tool for quality assurance and professional development but little is known about the impact of such activity on professional practice at the individual surgeon level. This paper reports the findings of a survey conducted with a self-selected cohort of surgeons in Queensland, Australia, on their experience of participating in the audit and its impact on their professional practice, as well as implications for hospital systems. METHODS: The study used a descriptive cross-sectional survey design. All surgeons registered in Queensland in 2015 (n = 919) were invited to complete an anonymous online questionnaire between September and October 2015. 184 surgeons completed and returned the questionnaire at a response rate of 20%. RESULTS: Thirty-nine percent of the participants reported that involvement in the audit process affected their clinical practice. This was particularly the case for surgeons whose participation included being an assessor. Thirteen percent of the participants had perceived improvement to hospital practices or advancement in patient care and safety as a result of audit recommendations. Analysis of the open-ended responses suggested the audit experience had led surgeons to become more cautious, reflective in action and with increased confidence in best practice, and recognise the importance of effective communication and clear documentation. CONCLUSIONS: This is the first study to examine the impact of participation in a mortality audit process on the professional practice of surgeons. The findings offer evidence for surgical mortality audit as an effective strategy for continuous professional development and for improving patient safety initiatives.

Improving outcomes from high-risk surgery: a multimethod evaluation of a patient-centred advanced care planning intervention.

INTRODUCTION: Patients who are frail, have multiple comorbidities or have a terminal illness often have poor outcomes from surgery. However, sole specialists may recommend surgery in these patients without consultation with other treating clinicians or allowing for patient goals. The Patient-Centred Advanced Care Planning (PC-ACP) model of care provides a framework in which a multidisciplinary advanced care plan is devised to incorporate high-risk patients' values and goals. Decision-making is performed collaboratively by patients, their family, surgeons, anaesthetists, intensivists and surgical case managers. This study aims to evaluate the feasibility of this new model of care, and to determine potential benefits to patients and clinicians. METHODS AND ANALYSIS: After being assessed for frailty, patients will complete a patient-clinician information engagement survey pretreatment and at 6 months follow-up. Patients (and/or family members) will be interviewed about their experience of care pretreatment and at 3 and 6 months follow-ups. Clinicians will complete a survey on workplace attitudes and engagement both preimplementation and postimplementation of PC-ACP and be interviewed, following each survey, on the implementation of PC-ACP. We will use process mapping to map the patient journey through the surgical care pathway to determine areas of improvement and to identify variations in patient experience. ETHICS AND DISSEMINATION: This study has received ethical approval from Townsville Hospital and Health Service HREC (HREC/16/QTHS/100). Results will be communicated to the participating hospital, presented at conferences and submitted for publication in a peer-reviewed MEDLINE-indexed journal.

Clinical events reported by surgeons assessing their peers.

BACKGROUND: All surgical deaths in Queensland, Australia are reviewed by external surgeon peers, and clinical events are recorded. The study objective was to classify clinical events in surgical patients who died. METHODS: Deaths notified to the Queensland Audit of Surgical Mortality between 2007 and 2013 were assessed by surgeons' peers who decided whether a clinical event occurred. The most serious clinical event per patient was analyzed. RESULTS: Peer surgeons reviewed 4,816 deaths. Most patients (70.7%) had no clinical event. Events were preventable in 58% of patients and less than 1 in 10 events was severe. The most frequent events were classified as patient assessment (34.5%), suboptimal therapy (15.3%), and delays (15.1%). CONCLUSIONS: Peer review of all surgical deaths identifies preventable clinical events and provides opportunities to improve decision making, better therapy and reduce delay in implementing appropriate surgical care. Review feedback to surgeons and other stakeholders should improve patient safety and quality.

A novel approach for emerging and antibiotic resistant infections: Innate defense regulators as an agnostic therapy.

Innate Defense Regulators (IDRs) are short synthetic peptides that target the host innate immune system via an intracellular adaptor protein which functions at key signaling nodes. In this work, further details of the mechanism of action of IDRs have been discovered. The studies reported here show that the lead clinical IDR, SGX94, has broad-spectrum activity against Gram-negative and Gram-positive bacterial infections caused by intracellular or extracellular bacteria and also complements the actions of standard of care antibiotics. Based on in vivo and primary cell culture studies, this activity is shown to result from the primary action of SGX94 on tissue-resident cells and subsequent secondary signaling to activate myeloid-derived cells, resulting in enhanced bacterial clearance and increased survival. Data from non-clinical and clinical studies also show that SGX94 treatment modulates pro-inflammatory and anti-inflammatory cytokine levels, thereby mitigating the deleterious inflammatory consequences of innate immune activation. Since they act through host pathways to provide both broad-spectrum anti-infective capability as well as control of inflammation, IDRs are unlikely to be impacted by resistance mechanisms and offer potential clinical advantages in the fight against emerging and antibiotic resistant bacterial infections.

Efficacy of a Gluten-Free Diet in Subjects With Irritable Bowel Syndrome-Diarrhea Unaware of Their HLA-DQ2/8 Genotype.

BACKGROUND & AIMS: A gluten-containing diet alters bowel barrier function in patients with irritable bowel syndrome with diarrhea (IBS-D), particularly those who are positive for HLA allele DQ2/8. We studied the effects of a gluten-free diet (GFD) in patients with IBS-D who have not previously considered the effects of gluten in their diet and were unaware of their HLA-DQ2/8 genotype. METHODS: We performed a prospective study of 41 patients with IBS-D (20 HLA-DQ2/8-positive and 21 HLA-DQ2/8-negative) at the Royal Hallamshire Hospital in Sheffield, United Kingdom, from September 2012 through July 2015. All subjects were placed on a 6-week GFD following evaluation by a dietician. Subjects completed validated questionnaires at baseline and Week 6 of the GFD. The primary endpoint was mean change in IBS Symptom Severity Score; a 50-point reduction was considered to indicate a clinical response. Secondary endpoints were changes in hospital anxiety and depression score, fatigue impact score, and Short Form-36 results. Clinical responders who chose to continue a GFD after the study period were evaluated on average 18 months later to assess diet durability, symptom scores, and anthropometric and biochemical status. RESULTS: A 6-week GFD reduced IBS Symptom Severity Score by ≥50 points in 29 patients overall (71%). The mean total IBS Symptom Severity Score decreased from 286 before the diet to 131 points after 6 weeks on the diet (P < .001); the reduction was similar in each HLA-DQ group. However, HLA-DQ2/8-negative subjects had a greater reduction in abdominal distention (P = .04). Both groups had marked mean improvements in hospital anxiety and depression scores, fatigue impact score, and Short Form-36 results, although HLA-DQ2/8-positive subjects had a greater reduction in depression score and increase in vitality score than HLA-DQ2/8-negative subjects (P = .02 and P = .03, respectively). Twenty-one of the 29 subjects with a clinical response (72%) planned to continue the GFD long term; 18 months after the study they were still on a GFD, with maintained symptom reductions, and demonstrated similar anthropometric and biochemical features compared with baseline. CONCLUSIONS: A dietitian-led GFD provided sustained benefit to patients with IBS-D. The symptoms that improved differed in magnitude according to HLA-DQ status. Clinical trials.gov no: NCT02528929.

Surgical mortality audit data validity.

BACKGROUND: Surgical audits provide constructive feedback to individual surgeons, hospitals and other healthcare sector professionals. Audits identify deficiencies in treatment processes, evaluate practice trends and detect practice gaps. The credibility and validity of the Queensland Audit of Surgical Mortality (QASM) relies on the accuracy of its data. METHODS: To determine the validity of routine reporting of surgical information to QASM, surgical case forms were compared against medical records (considered the gold standard). Data were extracted by a trained medical research assistant. QASM forensically reviewed 896 of a total of 5636 deaths in 20 Queensland public hospitals between 2008 and 2013. Concordance between the surgical case form and the relevant medical record was determined for 27 objective items. RESULTS: Overall concordance was 98.2%. The median concordance was 100% (interquartile range 87-100%). Cases with discordance were few and in these, most had only one discordant item. Discordances were mainly omissions. CONCLUSION: The QASM surgical case form is a reliable data collection tool that provides high-quality data. QASM objective data can be confidently regarded as accurate and therefore reliable for use in publications, reports and case studies.