The increase, first observed in 2020, is most apparent in General Surgery, the largest surgical specialty, and has been predominantly seen among emergency patients who did not undergo an operation. While the COVID-19 pandemic is likely to have contributed to the trend (as discussed in WAASM’s 2023 report), its persistence suggests that other factors may also be influencing surgical mortality.
WAASM aims to continuously improve surgical care through independent, external clinical review of patient deaths under the care of a surgeon, including where no operation was performed. Reviews are conducted by surgeons who practice in the same specialty but work at a different hospital.
The fact that many emergency patients did not undergo an operation needs to be considered in the context of the complexity and severity of their illness. WAASM has emphasised the importance of avoiding non-beneficial or futile surgery since its inception in 2002, and many emergency admissions involve patients at very high operative risk. WAASM Clinical Director, Dr James Aitken, suggested that the number of patients managed without surgery may reflect greater recognition by patients, families and clinicians that very high-risk surgery is unlikely to achieve outcomes that align with the patient’s goals of care.
However, this does not explain the overall rise in surgical deaths reported to WAASM. The factors contributing to this trend are not completely understood and are the subject of ongoing investigation.
For patients who do require emergency surgery, timely access to appropriate treatment is critical – minutes matter. Dr Aitken stated “the need for time-critical management of emergency surgery has been recognised for many years.
“Delayed theatre access is being reported in the Australian Clinical Quality Registries responsible for the two operations with the highest mortality, fractured neck of femur and emergency laparotomy. Australia is yet to develop a nationally consistent emergency surgery urgency categorisation.”
Dr Aitken said the WAASM report uses Statistical Process Control (SPC) charts to provide a clearer understanding of mortality trends over time and to identify changes that warrant further investigation. WAASM introduced SPC charts in its annual reporting three years ago and they have since become widely endorsed both internationally and nationally. Their use in Australia has been led by the Western Australian Department of Health and WAASM has been fortunate to benefit from the department’s expertise. SPC charts will also be used in the Australian and New Zealand Audit of Surgical Mortality dashboard currently under development.
