Anaesthesia Related Mortality 2003-2005

Anaesthesia Related Mortality 2003-2005 Quality Subcommittee Co-ordinating Committee in Anaesthesiology Hospital Authority 1 8 May 2007 Anaesthesia Related Mortality 2003-2005 Introduction: • A territory wide audit in anaesthesia has not been conducted • Quality Assurance (QA) Subcommittee of the Co-ordinating Committee in Anaesthesiology of the Hospital Authority, conducted a HA wide audit on anaesthesia related mortality • Incidence of anaesthesia related mortality between the years 2003 and 2005 • Analysed the factors leading to death associated with anesthesia 2 8 May 2007 Anaesthesia Related Mortality 2003-2005 Methodology (1): • The primary endpoint of this audit, death within 30 days after surgery, was detected by comparing this list of patients with the Hong Kong Government Births and Death Registry • Since we used the criterion of death within 30 days after surgery, the search was extended to include deaths occurred before 30th January 2006 • The HA Health Informatics Section, together with the assistance of in-house statisticians also facilitated the search process 3 8 May 2007 Anaesthesia Related Mortality 2003-2005 Methodology (2): • The list of patients who received anaesthesia in one of the 20 HA hospitals between 1st January, 2003 and 31st December, 2005, was initially identified by the Clinical Data Analysis and Reporting System (CDARS) • The CDARS is a powerful tool developed by HA in 2002, it can be considered as a mega data warehouse with inputs from a number of source systems 4 8 May 2007 Anaesthesia Related Mortality 2003-2005 Table 1. Hospitals (n = 20) participating in the anaesthesia related mortality audit Hong Kong East Cluster Kowloon West Cluster Pamela Youde Nethersole Eastern Hospital* Caritas Medical Centre Ruttonjee Hospital Kwong Wah Hospital Tung Wah East Hospital Our Lady of Maryknoll Hospital Hong Kong West Cluster Princess Margaret Hospital* Grantham Hospital Yan Chai Hospital Queen Mary Hospital* The Duchess of Kent Children’s Hospital New Territories East Cluster Tung Wah Hospital Alice Ho Mui Ling Nethersole Hospital Kowloon Central Cluster Prince of Wales Hospital* Hong Kong Eye Hospital North District Hospital Queen Elizabeth Hospital Kowloon East Cluster New Territories West Cluster United Christian Hospital* Tuen Mun Hospital* Tseung Kwan O Hospital 5 8 May 2007 Anaesthesia Related Mortality 2003-2005 Clinical Data Analysis and Reporting System (CDARS) of the Hong Kong Hospital Authority Source Name of system Information retrieved CMS Clinical Management System Diagonsis, Treatment, Specialist I/C, Medical Officer I/C, Operation Record Reporting System IPAS Inpatient Admission System Patient demographics, episode movements OPAS Outpatient Admission System Appointment & attendances information A&E Accident & Emergency Accident & Emergency attendances AEIS Attendance Episode Information Attendance information System PHS / CDDH Pharmaceutical Supply System / Drug dispensed Central Drug Dispensing History OBCIS Obstetrics Clinical Information Obstetric information System LIS Laboratory Information System Laboratory test with standardized units RIS Radiology Information System Radiology examination 6 8 May 2007 Anaesthesia Related Mortality 2003-2005 Mortality within 30 days of operation* Hospital 2003 2004 2005 Total A 28 15 27 70 B 94 77 92 263 C 0 0 1 1 D 41 39 28 108 E 5 8 4 17 F 140 140 112 392 G 136 130 150 416 H 0 1 6 7 I 120 174 169 463 J 157 204 195 556 K 168 169 166 503 L 419 379 386 1,187 M 256 241 231 728 N 65 59 42 166 O 42 42 57 141 P 227 217 259 703 Q 13 6 13 32 R 136 176 207 519 S 94 94 76 264 T 0 0 0 0 7 8 May 2007 Overall 2,141 2,171 2,221 6,533 Anaesthesia Related Mortality 2003-2005 Methodology (3): • All deaths were reviewed by a panel of specialist anaesthesiologists using the electronic patient record (e-PR) system and paper record of patients’ files, if deemed necessary • The causes of death were classified into 10 categories • The definition and classification were adopted from the Australian National Health and Medical Council, and the National Anaesthesia Mortality Committee • This classification was first described by Edwards and co-workers in 1956 8 8 May 2007 Anaesthesia Related Mortality 2003-2005 Methodology (4): • Cases were coded by a co-ordinator • Reviewed by the adjudication committee • Two members of the adjudication committee independently assessed the appropriateness of the classification • Disagreements were resolved by a third member • Cases that required reclassification were submitted to the adjudication committee again until a consensus was achieved • The final classification was further reviewed and endorsed by all members of the QA Subcommittee. 9 8 May 2007 Anaesthesia Related Mortality 2003-2005 Mortality Classification CASE CLASSIFICATION A. Deaths attributable to anaesthesia Category 1 Where it is reasonably certain that death was caused by the anaesthesia or other factors under the control of the anaesthesiologist. Category 2 Where there is some doubt whether death was entirely attributable to the anaesthesia or other factors under the control of the anaesthesiologist Category 3 Where death was caused by both surgical and anaesthesia factors. B. Death in which anaesthesia played no part Category 4 Surgical death where the administration of the anaesthesia is not contributory and surgical or other factors are implicated. Category 5 Inevitable death which would have occurred irrespective of anaesthesia or surgical procedures. Category 6 Incidental death which could not reasonably be expected to have been foreseen by those looking after the patient, was not related to the indication for surgery and was not due to factors under the control of anaesthesiologist or surgeon. C. Unassessable death Category 7 Those that cannot be assessed despite considerable data but where the information is conflicting or key data is missing. Category 8 Cases which cannot be assessed because of inadequate data. Category 9 A critical incident where a problem is identified but no mortality occurs. Category 10 Mortality in which anaesthesia and surgical techniques were apparently satisfactory. 10 8 May 2007 Anaesthesia Related Mortality 2003-2005 Table 4. Number of mortalities classified in each category Category Number of cases 1 10 (43.5%) 2 6 3 7 4 156 5 3,709 6 1,072 7 9 8 323 9 5 10 304 Organ harvesting 25 Duplicate files 907 Total 6,533 (5,601) 11 8 May 2007 Anaesthesia Related Mortality 2003-2005 Methodology (5): • Cases were sub-classified to explore the causal or contributory factors in anaesthesia related mortality • Subcategory classification was applied regardless of the patient’s condition prior to surgery • Medical condition contributed substantially to death, subcategory H was applied • No factor under the control of the anaesthesiologist that could or should have been done better, cases were then classified as subcategory G 12 8 May 2007 Anaesthesia Related Mortality 2003-2005 Causal or contributory factors in anaesthesia related mortality (subcategory) A. Pre-operative (i) Assessment This may involve failure to take an adequate history or perform an adequate examination or to undertake appropriate investigation or consultation or make adequate assessment of the volume status of the patient in an emergency. Where this is also a surgical responsibility the case may be classified in Category 3 above. (ii) Management This may involve failure to administer appropriate therapy or resuscitation. Urgency and the responsibility of the surgeon may also modify this classification. *Note that it is usual for more than one factor to be identified in the case of anaesthesia attributable death. 13 8 May 2007 Anaesthesia Related Mortality 2003-2005 Causal or contributory factors in anaesthesia related mortality (subcategory) B. Anaesthesia Technique (i) Choice or application There is inappropriate choice of technique in circumstances where it is contraindicated or by the incorrect application of a technique which was correctly chosen. (ii) Airway maintenance There is inappropriate choice of artificial airway or failure to maintain Including or provide adequate protection of the airway or to recognize pulmonary misplacement or occlusion of an artificial airway. aspiration (iii) Ventilation Death is caused by failure of ventilation of the lungs for any reason. This would include inadequate ventilator settings and failure or reinstitute proper respiratory support after deliberate hypoventilation (e.g. bypass). (iv) Circulatory support Failure to provide adequate support where there is haemodynamic instability, in particular in relation to techniques involving sympathetic blockade. 14 8 May 2007 Anaesthesia Related Mortality 2003-2005 Causal or contributory factors in anaesthesia related mortality (subcategory) C. Anaesthesia Drugs (i) Selection Administration of a wrong drug or one which is contraindicated or inappropriate. This would include “syringe swap” errors. (ii) Dosage This may be due to incorrect dosage, absolute or relative to the patient’s size, age and condition and in practice is usually an overdose. (iii) Adverse drug This includes all fatal drug reactions both acute such as anaphylaxis reaction and the delayed effects of anaesthesia agents such as the volatile agents. (iv) Inadequate This would include relaxant, narcotic and tranquillising agents reversal where reversal was indicated. (v) Incomplete e.g. prolonged coma. recovery 15 8 May 2007 Anaesthesia Related Mortality 2003-2005 Causal or contributory factors in anaesthesia related mortality

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