Learning from regret.

BACKGROUND: Death after surgery is infrequent but can be devastating for the surgeon. Surgeons may experience intense emotional reactions after a patient's death, reflecting on their part in the death and the patient's loss of life. Excessive rumination or feelings of regret may have lasting negative consequences, but these reactions may also facilitate learning for future decision-making. This qualitative study analysed surgeons' reflections on what might have been done differently before a patient's death and explored non-technical (cognitive and interpersonal) aspects of care as potential targets for improvement. METHODS: In Australia's Queensland Audit of Surgical Mortality, surgeons reflect on factors surrounding the death of patients in their care and respond to the open-ended question: in retrospect, would you have done anything differently? Framework analysis was applied to surgeons' responses to identify themes relating to non-technical aspects of care. RESULTS: Responses from 1214 surgeons were analysed. Two main themes were identified. Dilemmas and difficult decisions confirmed the uncertainty, complexity and situational pressures that often precede a surgical death; regret and empathy for patients featured in some responses. In the second main theme, communication matters, surgeons cited better communication, with patients, families, colleagues and at handover, as a source of reflective change to improve decision-making and reduce regret. CONCLUSION: Surgical decision-making involves uncertainty, and regret may occur after a patient's death. Enhancing the quality of communication with patients and peers in comprehensive assessment of the surgical patient may mitigate postdecision regret among surgeons.

Processes of care in surgical patients who died with hospital-acquired infections in Australian hospitals.

BACKGROUND: Infection may complicate surgical patients' hospital admission. The effect of hospital-acquired infections (HAIs) on processes of care among surgical patients who died is unknown. AIM: To investigate the effect of HAIs on processes of care in surgical patients who died in hospital. METHODS: Surgeon-recorded infection data extracted from a national Australian surgical mortality audit (2012-2016) were grouped into HAIs and no infection. The audit included all-age surgical patients, who died in hospital. Not all patients had surgery. Excluded from analysis were patients with community-acquired infection and those with missing timing of infection. Multivariate logistic regression was used to determine the adjusted effects of HAIs on the processes of care in these patients. Costs associated with HAIs were estimated. FINDINGS: One-fifth of surgical patients who died did so with an HAI (2242 out of 11,681; 19.2%). HAI patients had increased processes of care compared to those who died without infection: postoperative complications [51.0% vs 30.3%; adjusted odds ratio (aOR): 2.20; 95% confidence interval (CI): 1.98-2.45; P < 0.001]; unplanned reoperations (22.6% vs 10.9%; aOR: 2.38; 95% CI: 2.09-2.71; P < 0.001) and unplanned intensive care unit admission (29.3% vs 14.8%; aOR: 2.18; 95% CI: 1.94-2.45; P < 0.001). HAI patients had longer hospital admissions and greater hospital costs than those without infection. CONCLUSION: HAIs were associated with increased processes of care and costs in surgical patients who died; these outcomes need to be investigated in surgical patients who survive.

Analysis of deficiencies in care following cholecystectomy.

INTRODUCTION: Failure To Rescue was first defined in patients who died due to a complication following (open) cholecystectomy but research into the relevant factors has been scarce. This study was designed to determine a chronological sequence of deficiencies in care. METHODS: Adult patients who died under the care of a surgeon following cholecystectomy in Queensland were identified from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) database. RESULTS: Not unexpectedly, this is a high-risk patient population: median age of the 48 patients was 74.5 years and the median number of comorbidities and American Society of Anesthesiologists class was 4. Death occurred on postoperative day 6. Most deaths occurred at the end of the week. Over 80% of deaths followed emergency cholecystectomy. In almost half the patients, there were no deficiencies in care. Most common deficiency was during postoperative management (i.e. Failure To Rescue), however, significant deficiencies also arose prior to surgical admission; choice and timing of intervention as well as intraoperative decision-making. CONCLUSION: Surgeons who perform cholecystectomy need to be aware of the levels at which deficiencies arise given that many may be preventable.

Analysis of the causes and effects of delay before diagnosis using surgical mortality data.

BACKGROUND: The aim of the study was to assess the causes and effects of delay in diagnosis in surgical patients who died in 20 public hospitals participating in the Queensland Audit of Surgical Mortality (QASM) in Australia. METHODS: This was a retrospective cross-sectional analysis (June 2007 to December 2011) of deaths reported to QASM. Deaths were assigned to one of two groups (no delay or delay in diagnosis). Logistic regression was used to compare the association of delay with surgical complications, both overall and by surgical specialty. RESULTS: A total of 3139 deaths were reported. Diagnostic delay was reported in 293 (9·3 per cent). The primary cause of delay was attributed to diagnostic support services (41·7 per cent). Some 174 (13·8 per cent) of 1259 general (gastrointestinal) surgery patients experienced delayed diagnosis. Delay across all surgical specialties was associated with an increased risk of unplanned return to theatre (odds ratio (OR) 1·77, 95 per cent confidence interval 1·24 to 2·52), of being treated in intensive care (OR 1·71, 1·15 to 2·54) and of postoperative complications (OR 1·39, 1·05 to 1·85). CONCLUSION: General (gastrointestinal) surgery patients who experienced delayed diagnosis were at increased risk of postoperative complications.

Comprehensive health assessments during de-institutionalization: an observational study.

BACKGROUND: People with intellectual disability (ID) leaving institutions pass through a transition stage that makes them vulnerable to inadequate health care. They enter into community care under general practitioners (GPs) who are often untrained and inexperienced in their needs. Specifically designed health reviews may be of assistance to both them and their new GPs as they go through that phase. METHODS: This research aimed to investigate the effectiveness of a specially designed health review, the comprehensive health assessment program (CHAP) health review, in a group of adults as they transitioned out of the care of the last institution for people with ID in Tasmania. There were 25 residents reviewed by their GPs. RESULTS: The CHAP reviews picked up a number of health conditions and stimulated health promotion activities. Some of the findings were: a high number of abnormal Body Mass Indexes (19/23), immunizations given (13/23), vision impairment reported (2/23), mental health issues recorded (4/23) and skin abnormalities described (17/23). There were 22 referrals made to other health professionals (Australian Hearing Service 4, dentists 3, optometrists 3, psychiatrists 2, neurologists 2, ophthalmologist 1, urologist 1, ultrasound 1, mammogram 1, family planning 1, physiotherapist 1, continence nurse 1 and respiratory physician 1). These were in addition to various requests for pathology. CONCLUSIONS: The CHAP health review was effective in identifying a number of health issues in the population of people with ID as they transitioned out of institutional care into the general community.

Beating the barriers: recruitment of people with intellectual disability to participate in research.

BACKGROUND: The health status of people with intellectual disability (ID) is poor, yet very little research has been done on their health needs. There are several barriers to performing this research. The aim of our research was to examine the significant barriers encountered in recruiting adults with ID to participate in research. METHODS: Our project was a randomized controlled trial aiming to improve health advocacy of people with ID. We approached many organizations to recruit participants and kept records of our results. Recruitment was very low for the first 4 months. Then we adopted two new recruitment strategies--in-service telephone recruitment and meetings with prospective participants. We then monitored the subsequent recruitment rates. We also questioned participants about the difficulties they encountered when considering recruitment. RESULTS: Initial recruitment of participants yielded less than one-third of the expected number. Additional strategies implemented were partially successful. Significant barriers to recruitment included several sectoral issues and the challenges arising from the research process. CONCLUSIONS: While this population is a difficult one to reach for research, attempts to do so should not be abandoned, because the potential health benefits for this underserved group far outweigh the recruitment barriers experienced.