WA surgeons are facing the long tail of COVID and tightened rules about how they report deaths, as Cathy O’Leary reports.
Patients with long COVID who die under the care of a surgeon will be a new focus of WA’s annual audit into surgical-related deaths.
Established as a voluntary audit in 2002, the Western Australian Audit of Surgical Mortality is a peer-reviewed investigation of the care associated with surgery-related deaths to improve patient safety of quality of care.
WAASM is funded by the WA Health Department and has protection under federal legislation. Participation in the audit became a mandatory requirement of the Royal Australasian College of Surgeons in 2010, and since 2013 has been part of the RACS CPD program.
A review of more than 2800 deaths in the past five years, from 2017 to 2021, identified 571 clinical management issues, with 44 involving adverse events that caused death. Of those, 18 were considered preventable.
WAASM’s 2022 report, released in mid-October, recommends an ongoing review of the impact of COVID-19 on deaths under the care of a surgeon, given the increase in COVID cases in WA this year.
This includes a preliminary analysis of reported deaths in elective cases in patients aged 50 years and under or in regional hospitals (where complex cases are predominantly transferred to metropolitan tertiary hospitals) that are considered unexpected. The analysis of low-risk deaths is still in progress and is due to be reported in the 2023 WAASM report.
WAASM is continuing to ask surgeons to identify any patient deaths related to COVID-19. No data was received on this for the years 2020–2021, but audit staff are interested in reviewing this in the future.
Audit clinical director, general and colorectal surgeon Mr James Aitken said COVID-19 had been the dominant health theme for the past two years.
“Until early 2022, WA had minimal COVID infections and WAASM is not aware of any patient who had died directly or indirectly from COVID-19. This has changed following the widespread development of COVID-19 in WA from early 2022,” he wrote in the report.
Mr Aitken said any increase in deaths was likely to manifest itself directly or indirectly in different ways.
In the acute phase, there was evidence that patients with COVID should not have surgery for at least seven weeks after infection. For those presenting as an emergency, that may not have been possible.
And long COVID was likely to develop in at least 15% of infected patients.
“At the time of writing this report, there is no published data reporting the outcome of surgery in patients suffering from long COVID-19,” Mr Aitken said.
“COVID-19 has an impact on the microvascular circulation and other health conditions that impact on this (such as smoking and diabetes) that can increase complications. So, there is the potential for long COVID-19 to adversely affect surgical outcomes.”
Mr Aitken warned that restrictions on elective surgery during the pandemic had greatly increased waiting lists. Reducing the increased elective surgery backlog would be a major health priority for the next few years.
“Delaying emergency surgery has long been one safety valve used to prioritise elective lists, so they continue uninterrupted. There is a real risk that prioritising elective cases will delay theatre access for emergency operations. This will compromise emergency surgery outcomes and prolong hospital stay and hence costs.”
More broadly, Mr Aitken said that over the past 20 years there had been a substantial fall in operative-related mortality, which meant surgery in WA had never been safer.
While some of the improvements were likely to reflect improvements in practice, others reflected the direct impact of WAASM.
One of the trends seen in the first 10 years of the audit was an increase in the number of patients who died under the care of a surgeon but who did not have an operation. RACS believed this suggested a greater recognition of the limitations of surgery and reflected WAASM’s long-term interest in the use of futile surgery.
Mr Aitken said the necessary changes still needed were often systematic, slow to enact and complicated by wide annual variation. The audit cycle often had to be repeated and reinforced if improved care is to be sustained.
The development of clinical quality registries in Australia was many years behind other countries but it was rapidly changing. The key to the integrity of CQR was complete cases and data.
“The availability of more accurate and timely administrative data, coupled with artificial intelligence, is already changing the future,” Mr Aitken said.
“The traditional annual quality assurance ‘data dump’ is already being replaced with near real-time continuous quality improvement data that will increasingly extract and report daily data from administrative datasets. The United Kingdom’s Get It Right First Time program is a glimpse into the future and has already arrived in other Australian states.
“The WA Department of Health is actively engaged in the use of these new techniques. All WA clinicians, and those involved with WAASM, will have to engage with these new demands and at a rapidly accelerating rate.”
Mr Aitken said changes to WAASM would never have commenced without the protection provided by qualified privilege (QP), which was now under Commonwealth legislation.
The QP covering WAASM had recently been adjusted to permit it to identify to the WA Health Department any patient where assessors had identified a Health Roundtable 4 or 5 death.
But only patient identifiers would be provided. All WAASM information such as activities and report would continue to be covered by the same QP protection as previously.
Mr Aitken said this was a small but necessary step to ensure all deaths under a WA surgeon had been appropriately reviewed.
There were also looming changes to the reporting of CPD compliance from the start of 2023, which meant that for most surgeons RACS would become their accredited CPD ‘home’.
Tightening CPD
It was also a requirement of the RACS CPD program that surgeons return WAASM forms within two months – something that had not previously been strictly enforced.
“There is a new focus on encouraging and supporting fellows to comply with the standard to ensure timely completion of the audit requirements,” he said. “This is an important obligation to comply with.”
Mr Aitken also took a swipe at continued setbacks to the audit being able to access the Coroner’s reports, describing it as a major handicap for those seeking to learn from post mortem reports. “Change to the current legislation is now urgent and long overdue,” he said.