Mortality and Morbidity in Cardiothoracic Surgery in Australia

Abstract

Introduction: Identifying potentially modifiable factors leading to patient mortality in cardiothoracic surgery may provide the basis for interventions to improve patient safety. Australia is unique in that all cardiothoracic surgeons participate in a mandatory national surgical audit. All patients who die under the care of a surgeon are referred to the Australian and New Zealand Audit of Surgical Mortality (ANZASM). Surgeons are asked to provide a narrative to patient death and the case is reviewed by independent assessors with case note review if necessary. The aim of this project was to examine the ANZASM database for cardiothoracic mortality and identify possible factors leading to patient mortality. Methods: The ANZASM database was analysed for a seven-year period from February 2009 through December 2015. The surgeons’ narrative and assessors report of all patients who died under the care of a cardiothoracic surgeon were examined. A qualitative analysis using a thematic analysis technique was performed on the data set. Researchers read the surgical narrative and assessor report and common clinical management issues (CMIs) were coded from these extracts and subsequently grouped into a set of common themes. Within these themes, the reports were re-analysed to look in further detail about common factors and subthemes. Specific attention was paid to potentially avoidable themes. This process was repeated for the overall dataset, followed by the most common theme identified (operative technical factors) and again focusing on communication issues, which were identified as prevalent throughout all operative phases. Results: A total of 1440 CMIs were identified in 908 patients in our analysis. The CMIs were grouped into preoperative, intraoperative and postoperative phases. The most common individual CMI was intraoperative technical factors (31.7% of cases) and most CMIs occurred in the postoperative phase. Themes that were identified in the preoperative phase included: decision to operate (18.3%), inadequate assessment (13.1%) and delay to surgery (10.4%). Intraoperative themes comprised technical factors (31.4%), wrong surgical approach (6.6%) and junior surgeon (2.4%). Postoperative themes included inappropriate management (15.9%), delay to recognising complication (3.6%), postoperative bleeding (13.2%), infection (11.6%) and inadequate monitoring (2.6%). Technical factors affecting surgery were made up of unintentional injury to anatomical structures (42% of operative-phase CMIs), perfusion issues related to coronary grafts (15.4%), unaddressed surgical pathology (13%), inadequate myocardial protection (11.2%), air and anastomotic leaks (6.3%), bleeding (13.2%), technical issues with cardiopulmonary bypass (4.2%) and excessive surgery (3.8%). Communication issues identified were broken down into failure of shared decision making (41.8% of communication-related CMIs), failure to notify a patient deterioration (24.1%), misreporting of patient condition (11%) and issues regarding informed consent (10%). Conclusions: This thesis identified many factors leading to cardiothoracic surgical mortality throughout all operative phases. Technical and postoperative factors are the most common issues, however, most mortality results from multifactorial failures spanning the operative phases. National surgical audit is useful in identifying factors and maintaining safety standards for patient care perioperatively. Attention to correcting issues most commonly identified may improve the quality of patient care in cardiothoracic surgery.