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Background: Frailty, malnutrition and low socioeconomic status may mutually perpetuate each other in a self-reinforcing and interdependent manner. The intertwined nature of these factors may be overlooked when investigating impacts on perioperative outcomes. This study aimed to investigate the impact of frailty, malnutrition and socioeconomic status on perioperative outcomes., Methods: A multicentre cohort study involving six Australian tertiary hospitals was undertaken. All consecutive surgical patients who underwent an operation were included. Frailty was defined by the Hospital Frailty Risk Score, malnutrition by the Malnutrition Universal Screening Tool (MUST) and low socioeconomic status by the Index of Relative Socioeconomic Disadvantage. Linear mixed-effects and binary logistic generalised estimated equation models were performed for the outcomes: inpatient mortality, length of stay, 30-day readmission and re-operation., Results: A total of 21 976 patients were included. After controlling for confounders, malnutrition and socioeconomic status, patients at high risk of frailty have a mean hospital length of stay 3.46 times longer (mean ratio = 3.46; 95% confidence interval (CI): 3.20, 3.73; P value < .001), odds of 30-day readmission 2.4 times higher (odds ratio = 2.40; 95% CI: 2.19, 2.63; P value < .001) and odds of in-hospital mortality 12.89 times greater than patients with low risk of frailty (odds ratio = 12.89; 95% CI: 4.51, 36.69; P value < .001). Elevated MUST scores were also significantly associated with worse outcomes, but to a lesser extent. Socioeconomic status had no association with outcomes., Conclusion: Perioperative risk evaluation should consider both frailty and malnutrition as separate, significant risk factors. Despite strong causal links with frailty and malnutrition, socioeconomic disadvantage is not associated with worse postoperative outcomes. Additional studies regarding the prospective identification of these patients with implementation of strategies to mitigate frailty and malnutrition and assessment of perioperative risk are required., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Up to half of all surgical adverse events are due to non-technical errors, making non-technical skill assessment and improvement a priority. No specific tools are available to retrospectively identify non-technical errors that have occurred in surgical patient care. This original study aimed to develop and provide evidence of validity and inter-rater reliability for the System for Identification and Categorization of Non-technical Error in Surgical Settings (SICNESS)., Methods: A literature review, modified Delphi process, and two pilot phases were used to develop and test the SICNESS tool. For each pilot, 12 months of surgical mortality data from the Australian and New Zealand Audit of Surgical Mortality were assessed by two independent reviewers using the SICNESS tool. Main outcomes included tool validation through modified Delphi consensus, and inter-rater reliability for: non-technical error identification and non-technical error categorization using Cohen's κ coefficient, and overall agreement using Fleiss' κ coefficient., Results: Version 1 of the SICNESS was used for pilot 1, including 412 mortality cases, and identified and categorized non-technical errors with strong-moderate inter-rater reliability. Non-technical error exemplars were created and validated through Delphi consensus, and a novel mental model was developed. Pilot 2 included an additional 432 mortality cases. Inter-rater reliability was near perfect for leadership (κ 0.92, 95% c.i. 0.82 to 1.00); strong for non-technical error identification (κ 0.89, 0.84 to 0.93), communication and teamwork (κ 0.89, 0.79 to 0.99), and decision-making (κ 0.85, 0.79 to 0.92); and moderate for situational awareness (κ 0.79, 0.71 to 0.87) and overall agreement (κ 0.69, 0.66 to 0.73)., Conclusion: The SICNESS is a reliable and valid tool, enabling retrospective identification and categorization of non-technical errors associated with death, occurring in real surgical patient interactions., (© The Author(s) 2024. Published by Oxford University Press on behalf of BJS Foundation Ltd.)

Background: Health inequities persist among First Nations people living in developed countries. Surgical care is pivotal in addressing a significant portion of the global disease burden. Evidence regarding surgical outcomes among First Nations people in Australia is limited. The perioperative mortality rate (POMR) indicates timely access to safe surgery and predicts long-term survival after major surgery. This systematic review will examine POMR among First Nations and non-First Nations peoples in Australia., Methods: A systematic search strategy using MEDLINE, Embase, Emcare, Global Health, and Scopus will identify studies that include First Nations people and non-First Nations people who underwent a surgical intervention under anaesthesia in Australia. The primary focus will be on documenting perioperative mortality outcomes. Title and abstract screening and full-text review will be conducted by independent reviewers, followed by data extraction and bias assessment using the ROBINS-E tool. Meta-analysis will be considered if there is sufficient homogeneity between studies. The quality of cumulative evidence will be evaluated following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria., Discussion: This protocol describes the comprehensive methodology for the proposed systematic review. Evaluating disparities in perioperative mortality rates between First Nations and non-First Nations people remains essential in shaping the discourse surrounding health equity, particularly in addressing the surgical burden of disease., Systematic Review Registration: PROSPERO CRD42021258970., (© 2024. Crown.)

Background: Australia's ageing population is challenging for surgical units and there is a paucity of evidence for geriatric co-management in acute general surgery. We aimed to assess if initiating a Geriatric Medicine in-reach service improved outcomes for older adults in our Acute Surgical Unit (ASU)., Methods: The Older Adult Surgical Inpatient Service (OASIS) was integrated into ASU in 2021. We retrospectively reviewed all patients over age 65 admitted to ASU over a 12-month period before and after service integration with a length of stay (LOS) greater than 24 h. There was no subsequent truncation or selection. Primary outcomes were 30-day mortality, LOS, and 28-day readmissions. Secondary outcomes were discharge disposition, in-hospital mortality, and hospital-acquired complications (HACs)., Results: 1339 consecutive patients were included in each group, with no differences in baseline characteristics. There was a significant decrease in 28-day readmissions from 20.2% to 16.0% (P < 0.05), greatest in patients undergoing non-EL operative procedures (21.9% pre-OASIS vs. 12.6% post-OASIS; P < 0.05). Trends towards reduced 30-day mortality (7.17% vs. 5.90%; P = 0.211), in-hospital mortality (3.88% vs. 2.91%; P = 0.201), permanent care placement (7.77% vs. 7.09%; P = 0.843) and HACs (8.14% vs. 7.62%; P = 0.667) were seen, although statistical significance was not demonstrated. LOS remained unchanged at 4 days (P = 0.653)., Conclusion: The addition of a geriatric in-reach service to a tertiary ASU led to a significant reduction in 28-day readmissions. Downtrends were seen in mortality, permanent care placement, and HAC rates, while LOS remained unchanged., (© 2024 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: When applied to the pediatric population, the American Society of Anesthesiologists physical status (ASA-PS) classification has exhibited poor reliability due to its subjective and adult-focused definitions. This study was done to measure interrater agreement of a pediatric-adapted ASA-PS classification and to solicit multicenter perspectives to optimize the pediatric ASA-PS classification., Methods: A prospective, mixed-methods study of 197 pediatric anesthesiologists from 13 academic pediatric hospitals in the United States, Europe, and Australia surveyed in May and July 2019. Participants assigned ASA-PS scores (I to V) for 15 pediatric cases with a heterogeneous mix of acute and chronic health conditions undergoing a variety of surgical and related procedures. Pediatric-adapted definitions of ASA-PS were provided. The intraclass correlation coefficient (ICC) was used to assess interrater reliability of ASA-PS scores. The ICC was estimated using 2-way mixed-effects modeling, accounting for multiple raters assigning scores for the same set of cases. Qualitative feedback on the pediatric-adapted ASA-PS classification was analyzed with line-by-line coding., Results: The survey response rate was 83.8% (165 of 197). The ICC agreement among participants on ASA-PS scoring across all 15 clinical cases was 0.58 (95% confidence interval [CI], 0.42-0.77). ICC did not vary significantly by years of anesthesiology practice. ICC varied across hospitals (range: 0.34; 95% CI, 0.12-0.63 to 0.79; 95% CI, 0.66-0.91). The highest level of agreement occurred with cases most often scored as ASA-PS I, IV, and V; the lowest agreement occurred with cases most often scored ASA-PS II and III. Clarification of how well a chronic condition was controlled and presence of an acute illness were 2 common themes suggested to optimize the validity of the pediatric-adapted ASA-PS definitions., Conclusions: The pediatric-adapted ASA-PS classification had moderate interrater reliability among pediatric anesthesiologists. The lower reliability of scoring for ASA-PS II and III cases, in particular, supports the need for further ASA-PS definition refinement for pediatric populations., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 International Anesthesia Research Society.)

Background: Preoperative risk prediction is important for guiding clinical decision-making and resource allocation. Clinicians frequently rely solely on their own clinical judgement for risk prediction rather than objective measures. We aimed to compare the accuracy of freely available objective surgical risk tools with subjective clinical assessment in predicting 30-day mortality., Methods and Findings: We conducted a prospective observational study in 274 hospitals in the United Kingdom (UK), Australia, and New Zealand. For 1 week in 2017, prospective risk, surgical, and outcome data were collected on all adults aged 18 years and over undergoing surgery requiring at least a 1-night stay in hospital. Recruitment bias was avoided through an ethical waiver to patient consent; a mixture of rural, urban, district, and university hospitals participated. We compared subjective assessment with 3 previously published, open-access objective risk tools for predicting 30-day mortality: the Portsmouth-Physiology and Operative Severity Score for the enUmeration of Mortality (P-POSSUM), Surgical Risk Scale (SRS), and Surgical Outcome Risk Tool (SORT). We then developed a logistic regression model combining subjective assessment and the best objective tool and compared its performance to each constituent method alone. We included 22,631 patients in the study: 52.8% were female, median age was 62 years (interquartile range [IQR] 46 to 73 years), median postoperative length of stay was 3 days (IQR 1 to 6), and inpatient 30-day mortality was 1.4%. Clinicians used subjective assessment alone in 88.7% of cases. All methods overpredicted risk, but visual inspection of plots showed the SORT to have the best calibration. The SORT demonstrated the best discrimination of the objective tools (SORT Area Under Receiver Operating Characteristic curve [AUROC] = 0.90, 95% confidence interval [CI]: 0.88-0.92; P-POSSUM = 0.89, 95% CI 0.88-0.91; SRS = 0.85, 95% CI 0.82-0.87). Subjective assessment demonstrated good discrimination (AUROC = 0.89, 95% CI: 0.86-0.91) that was not different from the SORT (p = 0.309). Combining subjective assessment and the SORT improved discrimination (bootstrap optimism-corrected AUROC = 0.92, 95% CI: 0.90-0.94) and demonstrated continuous Net Reclassification Improvement (NRI = 0.13, 95% CI: 0.06-0.20, p < 0.001) compared with subjective assessment alone. Decision-curve analysis (DCA) confirmed the superiority of the SORT over other previously published models, and the SORT-clinical judgement model again performed best overall. Our study is limited by the low mortality rate, by the lack of blinding in the 'subjective' risk assessments, and because we only compared the performance of clinical risk scores as opposed to other prediction tools such as exercise testing or frailty assessment., Conclusions: In this study, we observed that the combination of subjective assessment with a parsimonious risk model improved perioperative risk estimation. This may be of value in helping clinicians allocate finite resources such as critical care and to support patient involvement in clinical decision-making., Competing Interests: The authors have declared that no competing interests exist.

Background: Peer review of surgical deaths can identify deficits in individual and systemic delivery of healthcare, ultimately informing quality improvement., Methods: From 2008 to 2016, cases reported to the Australia and New Zealand Audit of Surgical Mortality were analysed. Variables associated with peer-judged adverse events were sought., Results: Of 21 045 cases evaluated, 24.8% incurred at least one adverse event judgement. The proportion of cases with reported adverse event significantly decreased over time. Following adjustment for demographic and clinical characteristics, significant negative patient-related associations were advanced age, greater American Society of Anesthesiologists grade, and neurological and malignant comorbidities. Significant associations were also found with systemic or organizational factors, including state/territory, surgical specialty and hospital regionality., Conclusion: Examination of this peer-reviewed database revealed systemic or organizational predictors of adverse events that may have implications for quality improvement at an institutional or jurisdictional level. The extent to which these associations are due to the peer-review process itself should be the focus of further research., (© 2019 Royal Australasian College of Surgeons.)

Objective: The Victorian Audit of Surgical Mortality (VASM) is part of the Australian and New Zealand Audit of Surgical Mortality, aiming to identify factors associated with surgical mortality. A quality assurance method was utilised to rectify system issues through error rate checks of VASM data points. This method ensured data collected and entered in the audit database were accurate., Method: Clinical data was collected using case record forms (CRFs), entered from paper forms by VASM staff or by the surgeon into an online interface. Closed audited cases from 1 January 2012 to 31 December 2016 were analysed. From 5528 closed cases, 485 (8.8%) were reviewed, containing a total of 1117 CRFs and 169,789 data fields. Each CRF entered was visually inspected in the database against the source document by an independent audit staff member. The error rate for each period was calculated and considered acceptable below 10 per 10,000 fields., Results: Text errors made up the majority of data entry errors regardless of how the case was submitted., Conclusion: Application of error rate checks is beneficial to maintain good clinical data. This activity improved and streamlined the data collection process to reduce errors associated with data entry. Once the entry system was stabilised, a reduction in error rate was observed showing potential for further improvements. We acknowledge that errors cannot be entirely eliminated and it is unrealistic. By investigating the rigour of the data management processes based on research guidelines, the findings can contribute to improve quality of clinical audits., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: The World Health Organization Surgical Safety Checklist (WHO SSC) has been widely implemented in an effort to decrease surgical adverse events. The effects of the checklist on postoperative outcomes have not previously been examined in Australia, and there is limited evidence on the effects of the checklist in the long term., Methods: A retrospective review was conducted using administrative databases to examine the effects of the implementation of the checklist on postoperative outcomes. Data from 21,306 surgical procedures, performed over a 5-year time period at a tertiary care centre in Australia where the WHO SSC was introduced in the middle of this period, were analysed using multivariate logistic regression., Results: Postoperative mortality rates decreased from 1.2 to 0.92% [p = 0.038, OR 0.74 (0.56-0.98)], and length of admission decreased from 5.2 to 4.7 days (p = 0.014). The reduction in mortality rates reached significance at the 2-3 years post-implementation period [p = 0.017, OR 0.61 (0.41-0.92)]. The observed decrease in mortality rates was independent of the surgical procedure duration., Conclusion: Implementation of the WHO SSC was associated with a statistically significant reduction in mortality and length of admission over a 5-year time period. This is the first study demonstrating a reduction in postoperative mortality after the implementation of the checklist in an Australian setting. In this study, a relatively longer period examined, comparative to previous international studies, may have allowed factors like surgical culture change to take effect.

Objectives: It is assumed that increased age signifies increased surgical care. Few surgical studies describe the differences in care provided to older patients compared with younger patients. We aimed to examine the relationships between increasing age, preoperative factors and markers of postoperative care in adults who died in-hospital after surgery in Australia., Design: This retrospective cross-sectional study extracted data from a national surgical mortality audit--an independent, peer-reviewed process., Setting: From January 2009 to December 2012, 111 public and 61 private Australian hospitals notified the audit of in-hospital deaths after general anaesthetic surgery or if the patient was admitted under a surgeon., Participants: Notified deaths totalled 19,723. We excluded deaths if patients were brain dead, younger than 17 years or never had an operation (n=11,376). From this baseline population, we divided 11,201 deaths into three patient age groups: youngest (17-64 years), medium (65-79 years) and oldest (≥80 years)., Outcome Measures: Univariable and multivariable logistic regression analyses determined the relationships between increasing age and the measured preoperative factors and postoperative variables., Results: The baseline population's median age was 78 years (IQR 66-85), 43.7% (4892/11,201) were 80 years or older and 83.4% (9319/11,173) had emergency admissions. The oldest group had increased trauma and emergency admissions than the medium and youngest age groups. Seven of the eight measured markers of postoperative care demonstrate strong and significant relationships with increasing age. The oldest group compared with the medium group had decreased rates of: unplanned returns to theatre (11.2% (526/4709) vs 20.2% (726/3586)), unplanned intensive care admissions (16.3% (545/3350) vs 24.0% (601/2504)) and treatment in intensive care units (59.7% (2689/4507) vs 76.7% (2754/3590))., Conclusions: The oldest patients received lower levels of care than the medium and youngest age groups., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: This article outlines the formation of the Australian and New Zealand Audit of Surgical Mortality (ANZASM) and describes its objectives, governance, functioning and challenges., Background: A nationwide audit of surgical mortality provides an overview of the leading causes of death in patients who require surgical care. It identifies system or process errors, trends in deficiency of care and helps develop strategies to reduce deaths in the surgical arena., Methods: A standardized tool is used to systematically collect data after every surgical death. Patient details are reviewed by a peer surgeon (and in certain cases a second) to identify issues with patient management and hospital processes. The treating surgeon is then offered confidential feedback and alternate views on patient management., Results: From January 2009 to December 2012, 19,096 deaths were reported to the ANZASM. Eighty-six percent of the audited deaths occurred in patients requiring an emergency admission. Significant criticism of patient care was reported in 13% of cases with 16% of clinical issues perceived to be preventable. Western Australia, which first began the audit process, has shown a 30% reduction in surgical deaths., Conclusions: Nationwide mortality audits are a useful and worthwhile exercise. Recommendations identified in the audit reports direct educational workshops and seminars to address these issues. They allow Departments of Health to make informed decisions in their hospitals. Through this model, and the lessons learnt, we would encourage other countries planning to set up their own audits to follow a similar concept.

Background: The Australian and New Zealand Audit of Surgical Mortality (ANZASM) is a nationwide confidential peer review of deaths associated with surgical care. This study assesses the concordance between treating surgeons and peer reviewers in reporting clinical events and delays in management., Methods: This is a retrospective cross-sectional analysis of deaths in 2009 and 2010. Cases that went through the process of submission of details by the surgeon in a structured surgical case form (SCF), first-line assessment (FLA) and a more detailed second-line assessment (SLA) were included. Significant clinical events reported for these patients were categorized and analysed for concordance., Results: Of the 11,303 notifications of death to the ANZASM, 6507 (57.6%) were audited and 685 (10.5%) required the entire review process. Nationally, the most significant events were post-operative complications, poor preoperative assessment and delay to surgery or diagnosis. The SCF submissions reported 338 events, as compared with 1009 and 985 events reported through FLA and SLA, respectively (P = 0.01). Treating surgeons and assessors attributed 29-30% of events to factors outside the surgeon's control. Surgeons felt that delay to surgery or diagnosis was a significant event in 6.6% of cases, in contrast to 20% by assessors (P = 0.01). Preoperative management could be improved in 19% of cases according to surgeons, compared with 45 and 36% according to the assessors (P < 0.001)., Conclusion: There is significant discordance between treating surgeons and assessors. This suggests the need for in-depth analysis and possible refinement of the audit process., (© 2014 Royal Australasian College of Surgeons.)

Background: In this study, the Australian and New Zealand Audit of Surgical Mortality evaluated the effect of operative supervision on certain post-operative outcomes in the surgical death subset., Methods: This retrospective cohort study was based upon mortality data collected in 2009 which included 1673 patients who died and had surgery within 30 days of death or during the last admission. Cases were divided into three groups: consultant not supervising (group NS), consultant supervising (group S) and consultant performing the operation (group C). A comparison was done nationally and between participating states in Australia. Certain post-operative outcomes were compared between the three groups as well as between elective and emergency operations., Results: There were significant variations in the levels of operative supervision among states in Australia. Group NS (n = 468) generally had more favourable post-operative outcomes than group S (n = 147) and group C (n = 1058), with post-operative complication rates of 24.8%, 37.4% and 40.9% for groups NS, S and C, respectively. The level of operative supervision in emergency operations was half that of elective operations. Nevertheless, the post-operative complications rate was significantly lower in emergency operations (30.6%) compared with elective operations (64.4%). The same trend was seen with clinical management deficiencies and unplanned return to theatre., Conclusion: Operative supervision in emergency setting within Australian hospitals appears to be potentially inadequate. However, the available data suggest that unsupervised surgery did not result in worse post-operative outcomes. In appropriately selected cases, the data support surgical registrars performing surgery without consultant supervision., (© 2012 The Authors. ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons.)

We conducted a prospective study of non-cardiac surgical patients aged 70 years or more in 23 hospitals in Australia and New Zealand. We studied 4158 consecutive patients of whom 2845 (68%) had pre-existing comorbidities. By day 30, 216 (5%) patients had died, and 835 (20%) suffered complications; 390 (9.4%) patients were admitted to the Intensive Care Unit. Pre-operative factors associated with mortality included: increasing age (80-89 years: OR 2.1 (95% CI 1.6-2.8), p < 0.001; 90+ years: OR 4.0 (95% CI 2.6-6.2), p < 0.001); worsening ASA physical status (ASA 3: OR 3.1 (95% CI 1.8-5.5), p < 0.001; ASA 4: OR 12.4 (95% CI 6.9-22.2), p < 0.001); a pre-operative plasma albumin < 30 g.l⁻¹ (OR: 2.5 (95% CI 1.8-3.5), p < 0.001); and non-scheduled surgery (OR 1.8 (95% CI 1.3-2.5), p < 0.001). Complications associated with mortality included: acute renal impairment (OR 3.3 (95% CI 2.1-5.0), p < 0.001); unplanned Intensive Care Unit admission (OR 3.1 (95% CI 1.9-4.9), p < 0.001); and systemic inflammation (OR 2.5 (95% CI 1.7-3.7), p < 0.001). Patient factors often had a stronger association with mortality than the type of surgery. Strategies are needed to reduce complications and mortality in older surgical patients., (© 2010 The Authors. Anaesthesia © 2010 The Association of Anaesthetists of Great Britain and Ireland.)

Aim: To assess the effect of a Medical Emergency Team (MET) service on patient mortality in the 4 years since its introduction into a teaching hospital., Methods: Using the hospital electronic database we obtained the number of admissions and in-hospital deaths "before-" (September 1998-August 1999), "during education-" (September 1999-August 2000), the "run-in period-" (September 2000-October 2000), and "after-" (November 2000-December 2004) the introduction of a MET service, intended to review and treat acutely unwell ward patients., Results: There were 42,230 surgical and 112,321 medical admissions over the study period. During the education period for the MET the odds ratio (OR) of death for surgical patients was 0.82 compared to the "before" MET period (95% CI 0.67-1.00; p=0.055). During the 2 month "run-in" period it remained statistically unchanged at 1.01 (95% CI 0.67-1.51; p=0.33). In the 4 years "after" introduction of the MET, the OR of death for surgical patients remained lower than the "before" MET period (multiple chi(2)-test p=0.0174). There were 1252 surgical MET calls, and in December 2004 the ratio of surgical MET calls to surgical deaths was 1.76:1. In contrast, in-hospital deaths for medical patients increased during the "education period", the "run-in" period and into the first year "after" the introduction of the MET (multiple chi(2)-test p<0.0001). There were 1278 medical MET calls, and in December 2004 the ratio of medical MET calls to medical deaths was 1:2.47 (0.41:1). For each 12-month period, the relative risk of death for medical patients as opposed to surgical patients ranged between 1.32 and 2.40., Conclusions: Introduction of an Intensive Care-based MET in a university teaching hospital was associated with a fluctuating reduction in post-operative surgical mortality which was already apparent during the education phase, but a sustained increase in the mortality of medical patients which was similarly already apparent during the education phase. The differential effects on mortality may relate to differences in the degree of disease complexity and reversibility between medical and surgical patients.

Introduction: Introducing an intensive care unit (ICU)-based medical emergency team (MET) into our hospital was associated with decreased postoperative in-hospital mortality after major surgery. The purpose of the present study was to assess the effect of the MET and other variables on long-term mortality in this patient population., Methods: We conducted a prospective, controlled, before-and-after trial in a University-affiliated hospital. Participants included consecutive patients admitted for major surgery (surgery requiring hospital stay > 48 hours) during a four month control phase and a four month MET phase. The intervention involved the introduction of a hospital-wide ICU-based MET service to evaluate and treat ward patients with acutely deranged vital signs. Information on long-term mortality was obtained from the Australian death registry. The main outcome measure was patient mortality at 1500 days. Data on patient demographics, surgery undertaken and whether the surgery was scheduled or unscheduled was obtained from the hospital electronic database. Multivariable analysis was conducted to determine independent predictors of 1500-day mortality., Results: There were 1,369 major operations in 1,116 patients during the control period and 1,313 operations in 1,067 patients during the MET (intervention) period. Overall survival at 1500 days was 65.8% in the control period and 71.6% during the MET period (P = 0.001). Patients in the control phase were statistically less likely to be admitted under orthopaedic surgery, urology and faciomaxillary surgery units, but more likely to be admitted under cardiac surgery or neurosurgery units. Patients in the MET period were less likely to undergo unscheduled surgery. Multivariable analysis revealed that age, unscheduled surgery and admission under thoracic surgery, neurosurgery, oncology and general medicine were independent predictors of increased 1500-day mortality. Admission during the MET period was also an independent predictor of decreased 1500-day mortality (odds ratio 0.74; P = 0.005)., Conclusion: Introduction of a MET service in a teaching hospital was associated with increased long-term survival even after adjusting for other factors that contribute to long-term surgical mortality.

Our aim was to evaluate the technique, results and complications in 126 women with pulsion enterocoele treated with the combined abdominoperineal repair. Mean follow-up was 25 months with a range of 0-83 months. Operative morbidity included bladder trauma (0.7%), bowel injury (3.1%), wound breakdown (0.7%), infection (10%), pulmonary embolus (0.7%) and blood transfusion (40%). Longterm complications included prolonged urinary retention (11%), incisional hernia (4.7%) and constipation (40.4%). 92.4% of women were cured.

Objective: To determine what operations are being done on patients over 75 years in a private hospital, to observe performance in terms of justification, morbidity and mortality., Method: Retrospective audit of 100 patients over 75 years having surgery at an Adelaide private hospital., Results: Cystoscopy, inguinal herniorrhaphy, cataract and colon surgery were the most common procedures. One patient died--probably from a leaking aortic abdominal aneurysm. Four patients had significant morbidity in the form of burst abdomen, ruptured femoral-popliteal bypass graft, biliary collection requiring reoperation and cardiac arrhythmia requiring a pacemaker. Twenty three other patients had minor morbidity. No unnecessary operations were detected.