Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

The direction of the relationship between Helicobacter pylori and duodenal ulcer

Prevalence of H pylori was determined in 208 patients undergoing endoscopy for dyspepsia. Results were expressed separately for methods involving and not involving polymerase chain reaction (PCR). The results confirmed well-established findings such as a greater prevalence in duodenal ulcer patients than in groups with other diagnoses, and increasing prevalence with age. The unselected records of 320 different patients undergoing endoscopy for dyspepsia were studied using logistic regression analysis to determine factors significantly associated with a) DU and b) H pylori. It was found that number of endoscopies was significant for both regressions. In order to avoid the compounding effects of repeated endoscopies, a comparison was made in patients undergoing endoscopy for the first time in the series between those who had and those who had not undergone a previous endoscopy. This finding indicated that the relationship between prevalence and number of endoscopy was spurious. A search for the explanation revealed that the number of endoscopy was related to the duration of duodenal ulcer symptoms. Applying this information, it was found that 5 patients with symptom of 6 months were free of the infection, but the prevalence after 6 months was 96%. It is concluded that H pylori is most unlikely to be a prime factor in the aetiology of duodenal ulcer

PATIENT SAFETY IN SURGERY: THE QUALITY OF IMPLEMENTATION OF PATIENT SAFETY CHECKLISTS IN A REGIONAL HOSPITAL

Introduction. Patient safety and the avoidance of inhospital adverse events is a key focus of clinical practice and medical audit. A large of proportion of medical errors affect surgical patients in the peri-operative setting. Safety checklists have been adopted by the medical profession from the aviation industry as a cheap and reliable method of avoiding errors which arise from complex or stressful situations. Current evidence suggests that the use of periooperative checklists has led to a decrease in surgical morbidity and hospital costs. Aim. To assess the quality of implementation of a modified patient safety checklist in a UK district general hospital. Methods. An observational tool was designed to assess in real time the peri-operative performance of the surgical safety checklist in patients undergoing general surgical, urological or orthopaedic procedures. Initiation of the checklist, duration of performance and staff participation were audited in real time. Results. 338 cases were monitored. Nurses were most active in initiating the safety checklist. The checklist was performed successfully in less than a minute in most cases. 11-24% of staff (according to professional group) present in the operating room did not participate in the checklist. Critical safety checks (patient identity and procedure name were performed in all cases across all specialties. Variations were noted in checking other categories, such as deep vein thrombosis (DVT) prophylaxis or patient warming. Conclusions. There is still a potential for improving the practice and culture of surgical patient safety activities. Staff training and designation of patient safety leadership roles is needed in increasing compliance and implementation of patient safety mechanism, such as peri-operative checklists. There is significant data to advocate the need to implement patient safety surgical checklists internationall