From the Literature: New Mortality Study

N. Buck; H.B. Devlin; J.N. Lunn

Editor’s note: Suggestions are welcome for other pertinent articles from the anesthesia patient safety literature to be summarized in future issues.

Buck N, Devlin HB, Lunn JN: 7he &port of a Confidential Enquiry into Perioperative Deaths. London, Nuffield Provincial Hospitals Trust and The King’s Fund for Hospitals, 1987.

This is an interesting, and awe-some, 163-page report (including 230 tables) of The Confidential Enquiry into Perioperative Deaths (CEPOD), which summarizes the perioperative deaths occurring during a 12-month period (I 1/85-10/86) in National Health Service hospitals in three regions of Britain. A collaborative effort of the Association of Anesthetists and the Association of Surgeons of Great Britain and Ireland, this undertaking sought to determine ways to improve the delivery of surgical (including anesthesia) cam As the most recent and one of the largest such study, it represents an important addition to the literature on anesthetic related adverse outcomes and risk management in our specialty.

The study design was rather simple-. voluntary, confidential reporting of all deaths occurring within 30 days of surgery. The involved anesthesiologist and surgeon completed separate, detailed questionnaires which were “rendered anonymous” later destroyed). Blinded information on each case was sent to consultants in surgery and anesthesia who evaluated the appropriateness of surgery, adequacy of monitoring, quality of rare, and avoidability of the death. The consultants were also asked for a judgment on the contribution of the surgical condition, co-existing disease, anesthesia, and/or surgery to the death.

The study directors set out to review 4034 deaths occurring among more than half a million surgical procedures. (This gross mortality rate, 0.7 percent, is less than expected.) However, they were able to obtain information from both the surgeon and anesthesiologist for only 2391 deaths (59.3%), suggesting that, even in a country with a much less litigious atmosphere, voluntarism has severe limitations.

Consultants differed widely in their judgments: Surgeons and anesthesiologists attributed only 0. I percent of the deaths solely to an error in anesthesia management, and each discipline acknowledged that some 20 percent of deaths were due to avoidable factors in its sphere of activity. Interestingly, anesthesiologists felt that anesthesia and surgery each contributed to 14 percent of deaths, whereas surgeons accepted blame for 30 percent, leaving only 2 percent to anesthesia.

The most interesting, and sobering, results relate to more global aspects of the surgical experience: As expected, 79 percent of the deaths occurred in those over 65 years, whereas the elderly comprised only 2 percent of the surgical population of these hospitals. Consultants felt that the surgical disease caused a third of deaths and contributed to two thirds; similarly, co-existing disease accounted for about one fifth of deaths and contributed to one half. Overall, there was a strong suggestion that much surgery had been undertaken inappropriately in moribund or terminally ill patients who would not have benefited. The study also documented highly variable supervision of surgical and anesthesia house staff, as well as disturbingly high correlations of off-hours, unsupervised activity with sicker patients and higher mortality. Using their own classification of urgency of the surgery, the investigators also showed that few operations must be performed at night.

Although many of their conclusions relate specifically to the organization of surgical care delivery under the National Health Service, there is much in this report that is of broad generic applicability to the conduct of quality assurance and risk management programs. The report may be obtained from the Nuffield Provincial Hospitals Trust (3 Prince Albert Road, London NW I 7SP, England). A summary prepared by Drs. Lunn and Devlin, as well as an editorial, appeared in 7he Lancet (2:1384-1386 and 1369-1371, respectively, 1987).

Abstracted by Fredrick K. Orkin, M.D., Department of Anesthesia, University of California, San Francisco, School of Medicine.