Is mortality reporting nearing the end?
MORTALITY REPORTING IS ‘DEAD’; MORBIDITY REPORTING IS THE WAY FORWARD
P Mackay
Victorian Consultative Council on Anaesthetic Mortality and Morbidity, VIC
This presentation will demonstrate the utility in quality control of systematic qualitative review of anaesthesia-related morbidity conducted by an external panel of independent peers.
In 1976, the Victorian State Government followed the precedent set in New South Wales and established a Council of experts to review anaesthesia mortality. The appointed chairman, Kevin McCaul, showed much foresight by insisting that reports include morbidity as well as mortality. After 30 years the Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM) remains the single state committee in Australia which collects data on morbidity in anaesthesia.
VCCAMM defined anaesthesia-related morbidity as ‘any event, related to an anaesthetic procedure, which caused a life-threatening incident, temporary or permanent disability or significant distress’. Any reported incident that had the potential to affect patient safety but did not cause morbidity was classified as a ‘critical incident’.
The notification of morbidity to VCCAMM was initially slow. In the 1st report covering the years 1977-82 there were only 3 such incidents. However, in the 1990’s morbidity was increasingly notified and, since the year 2000, the frequency of anaesthesia-related mortality has remained relatively stable while there has been a substantial increase in the notifications of morbidity. The increase has in part been due to the participation of Quality Assurance Committees within Departments of Anaesthesia in teaching hospitals. In addition, for private specialists and general practitioners, there has been the incentive of the award of points for the ANZCA programme for the maintenance of professional standards (MOPS).
VCCAMM relies entirely on voluntary reporting. Hence, neither a numerator nor a denominator can be established. However, there is indirect evidence that the use of the information has influenced individual anaesthetists as well as organisations on safety issues. Convincing arguments would have been impossible without the cumulative evidence from the low frequency mortality notifications and the much higher frequency morbidity notifications. One can note some examples:
(i) Adverse effects of haemaccel eventually led to the admission by the manufacturer that there had been a change in the methods of production: the product was subsequently withdrawn from marketing.
(ii) The risks of air embolism from use of pressure infusion pumps was eventually accepted following a detailed submission to the Therapeutic Goods Administration: this led to obligatory incorporation of air trapping devices by manufacturers.
(iii) Notifications on adverse effects of hypotension led to the successful promotion of the principle of a ‘safe limit’ for lowering of blood pressure in the elderly or ‘at risk’ patients: this local knowledge is now reinforced in the world literature.
(iv) The receipt by the Victorian Quality Council of a submission on adverse events arising from acute pain management led to formal support for the development of a state-wide pain management ‘tool kit’ to provide uniformity in pain assessment and management, and avoidance of many of the adverse events that had been notified.
(v) The development of a website (http://www.health.vic.gov.au/vccamm) that includes regular reports and has enabled rapid feedback to practitioners on safety issues: these include drug errors and reactions: operating theatre policies on dispensing of drugs; management of peri-operative stridor in adults; and discharge information for patients after regional block anaesthesia.
Morbidity reports are frequent in the medical literature but these are limited in being either hospital-based reports on single cases, literature reviews or specific research investigations. Hence there is considerable delay in dissemination of cumulative knowledge about morbidity from anaesthesia. There is also serious concern over fragmentation of input and duplication of reporting systems, evidenced by the production of reports in Australia by the Anaesthesia Incident Monitoring System (AIMS), state-based VCCAMM, state-sponsored sentinel events programmes and ‘closed claims’ studies.
My Conclusion is:
(i) The study of anaesthesia-related mortality is far from dead but, based on the experience of VCCAMM, there is a strong need for an external review of morbidity, together with mortality, by an independent group of peers with expertise in subspecialties in anaesthesia and pain management.
(ii) The future assessment of adverse events in anaesthesia will not only involve data acquisition but should have a qualitative element in providing information which can identify unsuspected problems in a timely manner. Furthermore, such information should be useful to formulate hypotheses which can be tested prospectively in designed studies.
(iii) ANZCA, supported by the Australian and New Zealand Societies of Anaesthetists, should provide leadership in establishing a framework for the coordination of all quality assurance activities undertaken by Australian and New Zealand anaesthetists.
(iv) If such quality activities fail to remain under the direct control of the specialty, the reporting itself of both mortality and morbidity will become moribund.
Time of Presentation
Sunday 14 May 2006 - 1330-1500
