The information contained in this report has been prepared by the RACS NTASM Management Committee. NTASM is a declared quality improvement committee under section 7 (1) of the HealthServices(QualityImprovement)Act1994 (gazetted 26 July 2005).
The Australian and New Zealand Audit of Surgical Mortality, including NTASM, has protection under the Commonwealth Qualified Privilege Scheme under Part VC of the Health Insurance Act 1973 (gazetted 24 April 2022).
Published: January 2025
DATA FIGURES
DATA TABLES
Data
CLINICAL DIRECTOR’S REPORT
As the clinical director of NTASM, I am pleased to present this annual report along with a 5-year update for context. This publication continues to demonstrate the power of data-driven healthcare and further reinforces the unique challenges that Northern Territorians face, both patients and healthcare providers alike. While our population is not large compared to the rest of Australia, it is vastly more complex, with geography and demographics being at the forefront of many clinical decisions. Workforce shortages certainly don’t help and this has not been forgotten.
As we emerge from COVID, the data could be expected to be skewed and difficult to interpret. However, when perusing the following pages, I believe you will find some common themes continue to hold true. There are also encouraging areas of improvement. We have observed reductions in elective surgery deaths and interhospital transfer delays. When considering a mean transfer distance of 317 km, this is no mean feat. Fewer patients than ever have experienced complications and unplanned returns to theatre.
There are still some domains where we could do better, and to this end may I reinforce the benefit of reviewing your own personal data and feedback, which—whilst improving over time—could be enhanced. Reflecting on the feedback and insights of others is also often beneficial (see Appendix C).
From here, may I encourage you all to continue embracing the NTASM initiative. The true strengths of NTASM rely on engagement, participation and collegial feedback. This informs the data herein and aids everyone in learning from the past to inform our future.
Professor Justin Gundara NTASM Clinical Director
MANAGEMENT COMMITTEE CHAIR’S REPORT
As the NTASM Management Committee Chair, I believe you will find this annual report with a 5-year update informative and useful. The Territory continues to face staff shortages, especially anesthetist and nursing shortages that impact service delivery. Almost on a weekly basis, theatre cancellations occur as a result of staff shortages where emergency work needs to be prioritised over elective procedures. There are efforts from the Department of Health to improve the staff shortage. I suspect it will take some time before we see a significant change.
Despite the challenges described above, this annual report shows encouraging data on many aspects. We continue to perform well with consultant presence in theatre, reduction in unplanned returns to theatre, a significant drop in elective surgery mortality, and fewer overall postoperative complications and inter-hospital transfer delays. However, there are certainly areas that have emerged as less than satisfactory. This provides an opportunity for us to reflect on our service and seek improvement. Identifying areas where improvement is necessary is the main objective of the annual report and this will be well utilised by all those involved in safety and quality in this jurisdiction.
I would like to thank the NT Government for its ongoing support of NTASM and the team of staff who collect the data, perform the analysis and, finally, present the comprehensive report. I appreciate all the hard work that has gone towards this report. Finally, a note of thanks to the previous clinical director and staff for their significant contribution to NTASM.
Dr Manimaran Sinnathamby Director of General Surgery Consultant General and Breast Surgeon Royal Darwin Hospital
ABBREVIATIONS
ACTASM Australian Capital Territory Audit of Surgical Mortality
AIHW Australian Institute of Health and Welfare
ANZASM Australian and New Zealand Audit of Surgical Mortality
ANZCA Australian and New Zealand College of Anaesthetists
Ahpra Australian Health Practitioner Regulation Agency
ICD-10 International Classification of Diseases 10th revision
ICU intensive care unit
IQR interquartile range
NT Northern Territory
NTASM Northern Territory Audit of Surgical Mortality
QASM Queensland Audit of Surgical Mortality
QLD Queensland
RR risk ratio
RACS Royal Australasian College of Surgeons
RANZCOG Royal Australian and New Zealand College of Obstetricians and Gynaecologists
SCF surgical case form
SLA second-line assessment
TASM Tasmanian Audit of Surgical Mortality
TED thromboembolic deterrent
ACKNOWLEDGEMENTS
We thank the following individuals and organisations for their contribution to NTASM:
NT Government for funding NTASM
Assessors for diligently completing their assessments
Chair Dr Manimaran Sinnathamby, for his leadership and support
NTASM management committee for its wisdom and counsel
NTASM staff for systematically managing the process
NTASM MANAGEMENT COMMITTEE MEMBERS
Dr Manimaran Sinnathamby, Chair, NTASM Steering Committee, RACS
Dr Suresh Mahendran, Otolaryngology surgeon, Royal Darwin Hospital
Dr Mark Hamilton, Head of Department Vascular Surgery, Top End Health Service/Central Australia Health Service
Dr Kanishka Williams, Orthopaedic surgeon, Alice Springs Hospital
Professor Justin Gundara, Clinical Director, NTASM
NT DEPARTMENT OF HEALTH REPRESENTATIVE
Dr Sara Watson, General Manager, Royal Darwin Hospital
ANAESTHESIA REPRESENTATIVE
Dr Phil Blum, Deputy Director Department of Anaesthesia, Top End Health Service; and NT representative, ANZCA Mortality Subcommittee
OBSTETRICS AND GYNAECOLOGY REPRESENTATIVE
Dr Michelle Harris, RANZCOG representative
ANZASM STAFF
Professor Guy Maddern, Chair, ANZASM steering committee
Professor Wendy Babidge, General Manager, Research, Audit and Academic Surgery, RACS
Dr Helena Kopunic, Manager Surgical Audits, Research, Audit and Academic Surgery, RACS
NTASM STAFF
Professor Justin Gundara, Clinical Director
Dr Jenny Allen, Project Manager
Shakirra Grosskopf, Project Officer
Chloe Cao, Research Data Officer
Kyrsty Webb, Administration Officer
NTASM SUPPORT STAFF
Sonya Faint, Senior Project Officer, QASM
Candice Postin, Senior Project Officer, QASM
Trudy Dugan, Surgical Audit Officer, Royal Darwin Hospital
Helen Humphreys, Health Information Manager, Darwin Private Hospital
Susan Sullivan, Data Integrity Officer, Alice Springs Hospital
STATISTICIAN
Professor Robert S Ware, Griffith Biostatistics Unit, Griffith University
NT GOVERNMENT DEPARTMENT OF CORPORATE AND DIGITAL DEVELOPMENT DATA SERVICES, HEALTH REPORTING AND ANALYTICS TEAM
Peta Archer, Senior Data Analyst
Ken Lin, Data Analyst
Kanchana Gunathilaka, Data Analyst
Amit Yadav, Data Analyst
EXECUTIVE SUMMARY
Overview
The Northern Territory Audit of Surgical Mortality (NTASM) is an external, independent, peer-reviewed audit of care processes associated with surgical deaths in the Northern Territory (NT). Its purpose is to provide feedback to inform, educate, facilitate change and improve practice. Surgeons are encouraged to use this feedback to self-reflect and improve their practice. Hospitals and policymakers are encouraged to use NTASM feedback to develop strategies to address clinical management areas needing improvement and fill staffing gaps in the NT surgical workforce.
This report covers the period 1 July 2019 to 30 June 2024 (census date 1 October 2024). Each audit year covers the period from 1 July to 30 June.
NT baseline data
Section 6 of this report compares NT baseline data (all patients admitted to NT public hospitals who had an operation or surgical procedure performed by a surgeon, 1 January–31 December 2023) with NTASM data (in-hospital surgical deaths where a surgeon was responsible for or had significant involvement in the patient’s care, regardless of whether an operation was performed).
NT baseline data are provided by the NT Government Department of Corporate and Digital Development Data Services, Health Reporting and Analytics Team.
Patients
80.0% (325/406) of cases completed the audit process by the census date
Cardiovascular disease (66.3%; 187/282) was the most frequent comorbidity
81.1% (262/323) of patients received deep vein thrombosis (DVT) prophylaxis
Operations
81.5% (265/325) of patients had an operation
Postoperative complications
19.1% (50/262) of patients had a postoperative complication
Intensive care unit use
14.3% (38/265) of patients had an unplanned postoperative admission to an intensive care unit
Infections
40.7% (131/322) of patients had an infection
54.6% (71/130) of patients acquired the infection before admission
Traumas
24.3% (79/325) of patients had experienced trauma
Falls were the most frequent cause of trauma (59.5%; 47/79), followed by road traffic incidents (20.3%; 16/79) and violence (10.1%; 8/79)
Clinical management issues
Assessors considered that 15.4% (50/325) of patients had a clinical management issue (CMI)
72 CMIs were recorded across 50 patients
70.0% (35/50) of CMIs were considered preventable
Aboriginal and Torres Strait Islander people
36.6% (119/325) of NTASM surgical deaths were Aboriginal and Torres Strait Islander patients
Aboriginal and Torres Strait Islander patients had a median age of 55 years (IQR 47–66)
Assessors considered that 13.4% (16/119) of Aboriginal and Torres Strait Islander patients had a CMI
Comparison of audit data across the 5-year audit period
Table 1: NTASM data, 2019–2024
Abbreviations:
RECOMMENDATIONS
The following recommendations are derived from responses documented in this report and trends identified in previous NTASM reports. NTASM encourages stakeholders (surgeons and hospitals) and policymakers to consider these recommendations and to advocate for improvements in surgical patient care in the NT.
1. Surgical workforce sustainability and networking across jurisdictions
NT Department of Health to continue to recruit and retain surgeons in the NT
NTASM annual reports continue to highlight that the surgical workforce to patient ratio in the NT is below that of all other Australian regions. This report reveals that NT has only one vascular surgeon and one urology surgeon practising in the public system, although they are supported by Specialist International Medical Graduates (SIMGs).
RACS to strengthen communication with NT Department of Health and streamline surgical training
The Royal Australasian College of Surgeons (RACS) is encouraged to continue working with the NT Department of Health to strengthen the rural surgical workforce. RACS to review its SIMG program to assist rural regions to employ international graduates.
NTASM to facilitate surgeons networking across jurisdictions
2. Chronic disease and infection prevention education
NT Department of Health to continue public education around chronic disease and prevention
Chronic disease, including cardiovascular disease (CVD) and diabetes, continues to be prominent in this report for all patients. CVD was present in more than half of all NTASM patients (63.9% Aboriginal and Torres Strait Islander patients; 53.9% non-Indigenous patients). Diabetes was present in half of all Aboriginal and Torres Strait Islander patients (49.6%) and renal disease was present in 60.5%. Aboriginal and Torres Strait Islander patients continue to present to hospital with a greater number of infections (28.0%) than the number present in non-Indigenous patients (18.6%).
3. Health promotion for Aboriginal and Torres Strait Islander people
NT Department of Health to continue health education in rural and remote communities
NTASM consistently reports that Aboriginal and Torres Strait Islander surgical patients die at a younger average age than non-Indigenous patients. The average age gap detailed in this report is 19 years.
4. Refine NTASM processes and systems
NTASM and ANZASM to continue to refine and streamline processes
NTASM to develop a form to streamline data collection for anaesthetic cases
NTASM to increase communication with surgeons to reduce the median time to return surgical case forms (SCFs) to under 60 days
NTASM to collate and report on surgeon feedback provided on preventable clinical management issue (PCMI) forms
NTASM to include concordance analysis between surgeons’ reported reasons for cause of patient death and findings from the NT coroner
ADOPTED RECOMMENDATIONS
1. Surgical workforce sustainability
Additional rural and remote medically qualified staff employed
Urology and vascular surgeons now supported by SIMG staff
Neurosurgeons (2) working within NT private and public hospitals
2. NTASM process streamlined
NTASM continues to use secure file transfer systems for death notifications and medical records, which has now been extended to the anaesthetic process. NTASM continues to encourage locum surgeons to access medical records via the secure file transfer system to complete SCFs.
Timeliness of reporting to NTASM has improved. Hospitals now report to NTASM on a weekly basis, which has improved the time surgeons take to complete SCFs, reducing the median time to return SCFs from 75 days (2022–2023) to 50 days (2023–2024).
Since July 2022 NTASM has monitored the number of cases for which surgeons have downloaded their feedback. This assists NTASM in closing the loop regarding learning from the audit. NT surgeons have downloaded 64.8% (81/125) of their feedback since July 2022.
NTASM has streamlined the data collection for anaesthetic cases by using Microsoft Forms.
NTASM surgeons have been encouraged to perform audit assessments for regions outside of NT.
3. ANZASM process streamlined
ANZASM has amended data collection fields in the SCF to include entries for alcohol and smoking as cofactors, and fluid balance as either overload, dehydration or both.
ANZASM has amended the data collection field in first- and second-line assessment forms to include a question enquiring if the death was considered preventable.
ANZASM has made certain data fields mandatory to improve the accuracy of data collection.
ANZASM has implemented an online process for second-line assessments (November 2023).
ANZASM has received CPD approval for return of PCMI feedback forms. Surgeons receive one CPD point for each completed form returned.
4. ANZASM and CPD homes
CPD homes are the educational providers that deliver CPD programs and ensure that doctors registered with a CPD home meet their minimum CPD requirements. Participation in ANZASM is approved by the Australian Health Practitioner Regulation Agency (Ahpra) as a surgical high-level requirement for CPD homes. All surgeons must participate and complete ANZASM documents regardless of their preferred CPD home.
1. INTRODUCTION
KEY POINTS
NTASM is an external, surgeon-led peer-reviewed audit of patient deaths under surgical care. This report is a review of all surgical deaths notified during the period 1 July 2019 to 30 June 2024. This report presents a comparative analysis of the 325 cases that completed the full peer-review audit process.
1.1 Background
Surgery in the Northern Territory (NT) is safe and well-regulated. Only a small proportion of surgical patients die, with those deaths reviewed by consultant surgeons and peer surgeon assessors. The Royal Australasian College of Surgeons (RACS) facilitates this review process via the Northern Territory Audit of Surgical Mortality (NTASM). NTASM was established in 2010 and is government-funded by the NT Department of Health.
NTASM is an external, surgeon-led peer-reviewed audit of processes of care associated with surgery-related deaths in the NT. NTASM review is designed as a feedback mechanism to encourage participating surgeons to reflect on surgical care and practice following the death of a patient. Information submitted to NTASM by the treating surgeon provides an opportunity to identify areas where care could be improved. Surgical peers review and assess the clinical management of each patient (including hospital systems and processes) and provide feedback to the treating surgeon. The deidentified and aggregated results of these reviews are presented in this document.
Each self-assessment and peer-review assessment in the NTASM database provides valuable insight into current practice and opportunities for practice improvement. Ongoing refinements to NTASM processes enhance the quality and reliability of the data captured.
NTASM provides feedback as follows:
Surgeons receive assessor feedback of each case, which can be securely downloaded.
Surgeons receive online access to their audit data.
Surgeons receive an electronic copy of the NTASM annual report, which is also posted on the RACS website.
Surgeons receive deidentified summaries of assessments in the National Case Note Review Booklet, which presents cases from across Australia.
Surgeons receive a monthly deidentified summary of a case assessment in the Case of the Month
Participating hospitals receive reports of aggregated deidentified data comparing similar hospitals across Australia. This report covers surgery-related deaths from 1 July 2019 to 30 June 2024 (census date 1 October 2024). Data analysis relates to the date of patient death rather than the date of notification to NTASM. Some cases reported during this period will still be undergoing review at the census date. These cases will be included in the next NTASM report. Submission of incomplete data means denominators throughout this report occasionally differ.
1.2 Objectives
The objectives of the audit are to: encourage and support surgeons to self-appraise their clinical care management encourage and support surgeons to appraise the clinical care management of their peers inform, educate, facilitate change and improve practice by providing feedback on surgical deaths in the NT.
2. METHODS
2.1 Structure and Governance
NTASM is overseen by the Australian and New Zealand Audit of Surgical Mortality (ANZASM). ANZASM is managed by Research, Audit and Academic Surgery within the Operations and Partnerships portfolio of RACS. Surgeon participation in NTASM is mandated as part of the RACS continuing professional development (CPD) program (since January 2010).
The NTASM governance structure is illustrated in Appendix Section 8.1. NTASM is a declared quality assurance committee under Section 7 (1) of the HealthServices(QualityImprovement)Act1994 (gazetted 26 July 2005).
ANZASM, including NTASM, has protection under the Commonwealth Qualified Privilege Scheme under Part VC of the Health Insurance Act 1973 (gazetted 24 April 2022).
2.2 Methodology
NTASM defines a surgical death as the death of a patient under the care of a surgeon, even if the patient did not have an operation. The audit includes all deaths that occurred in NT hospitals while a patient was under the care of a surgeon.
NTASM includes all patient deaths that meet one of the following criteria:
The patient was under the care of a surgeon (surgical admission) and may or may not have had an operation.
The patient was under the care of a physician (medical admission) and subsequently had an operation.
The patient’s death was possibly or definitely related to anaesthesia during surgery or occurred within 48 hours of surgery.
The patient was a gynaecology-related case and may or may not have had an operation.
NTASM excludes all deaths where the patient was deemed terminal upon admission and did not have an operation. Admission for terminal care is not the same as being admitted and receiving capped care. Many patients are offered a period of active treatment on the basis that their care will not be escalated to include an operation. During this time, they might be admitted to an intensive care unit (ICU) and/or receive other interventions (e.g. dialysis, diagnostic scans, interventional radiology). These patients were not admitted for terminal care but for active capped care.
2.3 Audit process
The audit process combines surgeon self-refection with peer review of all surgical deaths in the NT to determine whether the death was a direct result of the disease process alone or whether aspects of patient management or hospital systems and processes may have contributed. Anaesthetists, obstetricians and gynaecologists may also participate in cases related to their specialties.
The audit process begins when a surgical or medical records department in an NT hospital notifies NTASM staff of a surgical death, or when a surgeon self-reports a surgical death. The overall audit process is coordinated by NTASM staff, as outlined in Appendix B.
2.4 Surgeon assessors
Surgeons participate in the audit in the following capacities:
as a surgeon who self-assesses the clinical management provided to a patient under review as a peer assessor who conducts a first-line (FLA) or second-line assessment (SLA).
First- and second-line assessors are surgical peers, possibly appointed from an Australian state or territory outside the NT to preserve anonymity and facilitate impartiality. Surgeons and peer assessors review cases to identify any clinical management issues (CMIs), including hospital systems and processes, where care could have been better. Patients may have more than one CMI reported; however, this report encompasses only one CMI per patient—that reported by the highest-level assessor (i.e. the second-line assessor if an SLA is performed, otherwise the first-line assessor).
Surgeons and assessors provide clinical judgement on one of the two possible outcomes:
1. The patient’s death was a direct outcome of the disease process and clinical management had no impact on the outcome.
2. Aspects of clinical management may have contributed to the death of the patient.
In the case of the latter, surgeons and assessors may identify CMIs, which are classified as follows: area of consideration: the assessor believes an area of care could have been improved or different but recognises there may be debate about this area of concern: the assessor believes that an area of care should have been better adverse event: the assessor identifies an unintended injury caused by medical management rather than the disease process, which is sufficiently serious to either: lead to prolonged hospitalisation lead to temporary or permanent impairment or disability of the patient at the time of discharge contribute to or cause death.
Surgeons and assessors are asked to:
report the impact of the CMI on the outcome using accepted categories:
made no difference to the death may have contributed to the death caused the death of a patient who would otherwise have been expected to survive
provide an opinion on whether the CMI was preventable using accepted categories: definitely probably probably not definitely not
indicate with whom the CMI was associated using accepted categories:
2.5 Obstetrician and gynaecologist assessors
audited surgical team another clinical team hospital
Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Fellows began participating in NTASM in 2012. Obstetricians and gynaecologists voluntarily participate in the audit as first- or second-line assessors if the patient was a gynaecology-related case. The assessment process for obstetricians and gynaecologists is the same as for surgeons. These reviews are mostly of gynaecological cases.
2.6 Anaesthetist assessors
Australian and New Zealand College of Anaesthetists (ANZCA) Fellows began participating in NTASM in August 2016. Anaesthetists voluntarily participate in the audit and self-assess the clinical management provided to a patient under review if the death was related to anaesthesia during surgery. NT anaesthetists also perform anaesthetic peer assessments (first- or second-line) for the Australian Capital Territory Audit of Surgical Mortality (ACTASM) and the Tasmanian Audit of Surgical Mortality (TASM). TASM and ACTASM anaesthetists correspondingly assess NTASM anaesthetic cases.
2.7 Providing feedback
The core purpose of NTASM is to improve patient outcomes by providing detailed feedback to surgeons and hospitals to inform, educate, facilitate change and improve practice. Improvement at an individual, hospital or group level is achieved via feedback on individual cases; distribution of hospital reports, the NationalCaseNoteReviewBooklet,Case of the Month and the annual NTASM report; and provision of seminars and webinars.
2.8 Data analysis/reporting conventions
NTASM audits all surgery-related deaths occurring in NT hospitals. This 2024 report covers deaths reported to NTASM from 1 July 2019 to 30 June 2024 (census date 1 October 2024). The full audit process can take 3 months or longer from the initial notification of a death, so some cases were still under review as of the census date with outcomes unavailable for this report. Case numbers in previous reports may differ from those in this report because of cases completed after the relevant census dates.
Patients admitted specifically for terminal care are excluded from the full audit process. Cases are included if the patient was admitted with the intention to treat but after assessment it was decided to manage the patient conservatively or to palliate. Data are entered and stored in the binational audit system (BAS) database. Since data are incomplete for some cases (e.g. incomplete surgical case forms [SCFs] or assessment forms), the total number of cases for each analysis may vary.
2.9 Data management, storage and analysis
All data reported by NTASM are deidentified to preserve the confidentiality of the patient, the surgeon and the hospital. Data are encrypted and stored in the BAS database. Transactions are time-stamped and all changes to audit data are added to an archive table to provide a complete audit trail for each patient case. The database has an integrated workflow rules engine enabling NTASM staff to generate letters, reminders and management reports. NTASM staff routinely cross-check data for online SCF, FLA and SLA forms. Data are cleaned using logic testing and manually reviewed before analysis.
2.10 Statistical analysis
Statistical analysis and graphs are performed using R (version 4.4.0) and RStudio (version 2023.09.1).
Numbers in parentheses (n) represent the number of cases analysed. The total number of patients for each analysis varies because not all data points in the original SCF were completed. The total number of cases (n) included in each analysis is provided for all tables and figures throughout the report.
Continuous variables are summarised using medians and interquartile range (IQR), with the IQR being the values of the 25th and 75th percentiles of the variable. Reporting IQRs overcomes the problem of reporting the range (minimum–maximum), as extreme values do not overly influence the data interpretation.
Risk ratios (RRs) (reported with 95% confidence interval [CI]) are calculated for variables that have a dichotomous outcome, to assess the risk of an event in one group (comparator group) versus the risk of the event in another group (reference group). RRs are interpreted as follows:
hospital RR > 1: patients in the comparator group are more likely to have the outcome of interest than patients in the reference group.
hospital RR ≈ 1: no difference or little difference in risk between patients in the comparator and reference groups. hospital RR < 1: patients in the comparator group are less likely to have the outcome of interest than patients in the reference group.
Statistical significance (p) is set at < 0.05. The p value is a statistical measurement used to validate a hypothesis against observed data. The p value measures the probability of obtaining the observed results, assuming that the null hypothesis is true. The lower the p value, the greater the statistical significance of the observed difference. (Statistical significance means that the sample effect is unlikely to be caused by sampling error. Statistically significant results indicate an actual effect existing in the population).
Qualitative responses are analysed by NTASM staff and classified into themes.
Comorbidities and diagnoses for NT baseline data are provided by the NT Government with International Classification of Diseases (ICD) codes (10th revision, version 12). To enable comparison with NTASM data, NTASM recodes the ICD-10 categories to match the SCF categories.
3. RESULTS
KEY POINTS
100% of NT hospitals (public and private) participate in NTASM
66 days (IQR 26.5–135) is the average time surgeons take to complete and return SCFs
96.6% (393/407) of SCFs have been returned for the audit period
64.8% (81/125) of feedback letters have been downloaded by surgeons since July 2022
15.4% (50/324) of patients had a preoperative transfer
87.4% (284/325) of patients had one or more comorbidities present
81.1% (262/323) of patients received DVT prophylaxis
66.5% (216/325) of patients were treated in ICU
81.5% (265/325) of patients had one or more operations
434 operations were performed
80.2% (348/434) of operations had a consultant surgeon present in theatre in any capacity
40.7% (131/322) of patients had a clinically significant infection
24.3% (79/325) of patients were admitted to hospital due to trauma
3.1 Audit participation
3.1.1 Deaths reported to NTASM
This report contains a comparative analysis of the 325 cases that completed the full peer-review process reported to NTASM from 1 July 2019 to 30 June 2024 (Table 2).
A total of 406 deaths were reported to NTASM, of which 14 cases did not meet the inclusion criteria. Of the 392 cases meeting the NTASM criteria, 49 were excluded as terminal care, 13 are awaiting surgeon completion and 5 are awaiting assessor completion. The full peer-review process was completed for 325 cases (94.5%, 325/343).
NTASM feedback depends on timely completion of SCFs by surgeons. Throughout the reporting period, the median time for a surgeon to complete an SCF was 66 days (IQR 26.5–135).
Table 2 : NTASM cases at census date, 2019–2024
Source: Appendix E, Data Table 1 and 2.
3.1.2 Time for surgeon to return SCF
Surgeons have responded to the improved weekly reporting of notifications to NTASM by reducing the time taken to return completed SCFs from a median of 75 days in 2022–2023 to 50 days in 2023–2024 (Table 3).
NTASM aims to reduce the return time to less than 60 days.
Table 3: Days taken for surgeons to return surgical case forms
3.1.3 Feedback downloaded by surgeons
Review of NTASM feedback can improve patient care. In June 2022, ANZASM implemented a new function of the audit system allowing surgeons to securely access, review and download their audit feedback online. Using this feature, NTASM can monitor the number of cases where surgeons have downloaded their feedback.
From 1 July 2022 (when data gathering commenced) to 1 October 2024, NT surgeons downloaded feedback for 64.8% (81/125) of cases.
Table 4 shows the proportion of cases with feedback downloaded by surgeons according to the year that the death notification was received. Feedback could relate to cases notified in the previous reporting period.
Table 4: Proportion of cases with feedback downloaded by surgeons
3.1.4 Hospital participation
All public and private hospitals certified to provide surgical services in the NT participate in NTASM. These hospitals had notified NTASM of 406 patient surgical deaths by the census date (1 October 2024). The NTASM review process was completed for 325 patients.
Surgical deaths occurred predominantly in public hospitals (96.3%; 313/325), with a small proportion in private (3.1%; 10/325) and co-located hospitals (0.6%; 2/325). According to the Australian Institute of Health and Welfare (AIHW), many interventions occur for acute overnight separations in the public sector in the NT (no data provided for the private sector). A separation is a completed episode of care for an admitted patient. Some patients may have multiple separations during an admission (Section 8.4). 1
3.1.5 Surgeon participation
Surgical specialty
Surgeons participate in NTASM as treating surgeons (responsible for the case under review), peer review surgeons providing FLAs or SLAs, locums or Specialist International Medical Graduates (SIMGs).
As of October 2024, 61 consultant surgeons in NT public and private hospitals across 9 specialties were participating in the audit (Table 5). The NT relies extensively on locum surgeons and SIMGs, with 45 locum surgeons and 10 SIMGs (within Plastic and Reconstructive, General, Urology, Vascular, Orthopaedics, Ophthalmology, Neurosurgery and Otolaryngology Head and Neck Surgery) currently participating in NTASM.
Table 5: Participating NT surgeons by surgical specialty, as of October 2024
Note: *Surgeons who are locums (n = 45), Specialist International Medical Graduates (n = 10), ophthalmologists (n = 6) or rural and remote surgeons (n=3) in the NT are excluded.
Surgeon views in retrospect
Surgeons are asked within the SCF to consider whether—in retrospect—they would have done anything differently in terms of patient management.
For 86.1% (278/323) of patients, the surgeon would not have changed the management. For 13.9% (45/323) of patients, the surgeon would have done something differently. No answer was provided for 2 cases (2/325).
The areas of care that surgeons identified for improvement covered all aspects of patient management. Sample comments provided in Appendix C highlight the ability of surgeons to self-reflect and learn from experience.
Surgeon communication
The SCF asks surgeons if the case involved a communication issue. Surgeons indicated that communication was an issue in 5.2% (17/325) of cases and not an issue in 91.7% (298/325) of cases (unknown in the remaining cases). The SCF does not capture information about the source (patient, patient’s family or community member, clinical team member etc.) or nature (patient cognitive impairment, family unwilling to discuss palliative care etc.) of the communication issue. Surgeon reports of communication issues have remained low over the 5-year reporting period (Table 6). Nevertheless, the NTASM management committee has identified communication as a focus area for surgeons.
Table 6: Communication issues reported by consultant surgeons
Obstetrician and anaesthetist participation
RANZCOG Fellows began participating in NTASM in 2012. Obstetricians and gynaecologists voluntarily participate in the audit if a patient’s death was gynaecology related.
Three gynaecology cases were reported to NTASM; 15 obstetricians and gynaecologists participated in the audit. As the number of cases is small, these cases are included in the reported totals and not discussed separately as gynaecology cases.
ANZCA Fellows began participating in NTASM in August 2016. Anaesthetists voluntarily participate in the audit if a patient’s death was possibly or definitely related to anaesthesia during surgery or occurred within 48 hours of surgery. As of the census date, there were 47 participating anaesthetists, 9 of whom were general practitioner (GP) anaesthetists. Anaesthetist participation depends on a surgeon noting an anaesthetic-related death on the SCF or anaesthetists self-notifying NTASM of cases in which they are involved (Appendix B). There were 65 cases reported to NTASM, with 64 having completed the review process. Aggregated data from anaesthetic cases are included in the ANZCA Safety of Anaesthesia triennial reports.
3.2 Demographic profile of audited cases
3.2.1 Patient sex and age
Of the 325 NTASM patients, 188 were male and 137 were female. More males than females died during surgical admissions in NT hospitals in all years (2019–2024) (Appendix E, Data Table 3).
The median age of surgical patients who died was 67 years (IQR 53–78; n = 325). The 5-year age category with the greatest number of deaths was 75–79 years (Figure 1 and Appendix E, Data Table 4).
Note: n = 325
Source: Appendix E, Data Table 5.
Figure 1: Age distribution of NTASM patients, 2019–2024
3.2.2 Comorbidities
Surgeons record all known comorbidities (coexisting medical conditions that threaten life) in NTASM patients. Most patients had at least one comorbidity (87.4%; 284/325); 41 patients had no comorbidities (12.6%; 41/325)
Of patients with comorbidities, 11.3% (32/282) had 1 comorbidity and 88.7% (250/282) had 2 or more comorbidities. The median number of comorbidities was 4 (IQR 3–5) and the maximum was 9. Cardiovascular disease (CVD), at 66.3%, was the most frequently reported comorbidity (Figure 2 and Appendix E, Data Table 6). Comorbidity type was unreported for 2 patients.
Note: n = 282, data missing n = 2
Source: Appendix E, Data Table 6.
Figure 2: Type Presence of comorbidities, 2019–2024
3.3 Risk management strategies
3.3.1 Interhospital transfer
Table 7 shows that from 1 July 2019 to 30 June 2024, 15.4% (50/324) of audited deaths had an interhospital transfer (data missing n = 1) and 20.8% (10/48) of these were reported to have had a delay in transfer (data missing n = 2). The median transfer distance was 317.5 km (IQR 262–648). Surgeons reported that the transfer was appropriate for all transferred patients (100.0%; 49/49) and sufficient clinical information was provided with the transfer in 95.9% (47/49) of audited deaths with transfer.
Table 7: Interhospital transfer and delay in transfer, 2019–2024
Note: *data missing n = 1; **data missing n = 2
3.3.2 Prophylaxis for deep vein thrombosis
Deep vein thrombosis (DVT) prophylaxis is provided to most patients, regardless of whether they have an operation or not. Surgeons document any DVT prophylaxis used and comment on its appropriateness.
Most patients were provided with DVT prophylaxis (81.1%; 262/323). For 18.9% (61/323) of patients, DVT prophylaxis was not provided (data missing 0.6%; 2/325 cases).
Surgeons stated they did not give DVT prophylaxis in the following situations: use not appropriate (62.3%; 38/61) active decision to withhold (27.9%; 17/61) use not considered (9.8%; 6/61).
Surgeons stated that DVT prophylaxis was not provided to these patients (93.4% (57/61) for the following reasons: active bleeding (42.1%; 24/57) coagulopathic (12.3%; 7/57) already anticoagulated (5.3%; 3/57) palliation being provided (8.8%; 5/57).
Some patients received more than one DVT prophylactic agent. Surgeons provided 432 individual DVT prophylactic agents to 262 patients. The most frequently used DVT prophylaxis was heparin in any form (Table 8).
Abbreviations: DVT = deep vein thrombosis; TED = thromboembolic deterrent Notes: 432 uses of DVT prophylactic agent for 262 patients.
*Other includes: apixaban, enoxaparin/Clexane and rivaroxaban/Xarelto, dual antiplatelet therapy, calf compressors or inferior vena cava filter already inserted.
Table 8: DVT prophylaxis usage in NTASM patients, 2019–2024
3.3.3
Provision of critical care support
Planned or unplanned admission to ICU can occur at any time during a patient’s hospital stay, regardless of whether the patient has an operation or not. Surgeons record whether the patient was admitted to ICU.
Nearly three-quarters of all NTASM patients were treated in ICU (66.5%; 216/325). Fewer patients who did not have an operation were treated in ICU (56.7%; 34/60) compared with those patients who had an operation (68.7%; 182/265), although this difference is not statistically significant (RR 0.83; 95% CI 0.65–1.04).
Postoperative admission to ICU should be planned during preoperative assessments. Unplanned admission to ICU increases the risk of in-hospital mortality in geriatric trauma patients (those age 65 and older) 2 and is a reportable quality indicator used by the Australian Council of Healthcare Accreditation. Unplanned admission to ICU occurred for 21.9% (58/265) of NTASM patients who had an operation. Of NTASM patients age 60 years or older, 19.7% (42/213) had an unplanned admission to ICU. Of NTASM patients age under 60 years, 18.8% (21/112) had an unplanned admission to ICU.
The median age of patients treated in ICU was 64 years (IQR 50–73) and there were more males (118; 54.6%) than females (98; 45.4%). Less than a quarter of NTASM patients were 80 years or older (20.0%; 65/325). Of these patients, 9.2% (6/65) had an unplanned admission to ICU.
The median ASA grade (American Society of Anesthesiologists physical status classification system) for patients treated in ICU was IV (IQR III-V), with 73.8% of patients (152/206; data missing n = 10) at grade IV or higher.
Some NT patients require an interhospital transfer to receive ICU treatment. Of the 37 patients transferred and treated in ICU, 21.6% (8/37) did not have an operation.
3.4 Profile of operative intervention
3.4.1 Operation frequency
In this report, the term operation encompasses both operations and procedures (i.e. an operation may refer to a relevant radiological or endoscopic procedure).3
Most NTASM patients (81.5%; 265/325) admitted under the care of a surgeon had an operation; 18.5% (60/325) did not have an operation. Two-thirds of patients (70.2%; 186/265) had one operation.
Surgeons performed 434 operations, with consultant surgeons performing 59.0% (256/434) of these. Table 9 shows the most frequently performed operations across 2019–2024, representing 48.2% (209/434) of all operations.
Table 9: Most frequently performed operations, 2019–2024
Abbreviation: NEC = not elsewhere classified Note: n = 209
3.4.2 Preoperative diagnostic delays
Delays in surgical diagnosis are associated with higher mortality rates in surgical patients.4 During 2019–2024, 6.0% (16/265) of patients had a delay in surgical diagnosis. Delays in diagnosis were highest in 2023–2024 and lowest in 2022–2023 (Figure 3).
The causes of delays can be associated with more than one department or area. Most delays were associated with medical departments (43.8%; 7/16), surgical departments (37.5%; 6/16) or GPs (18.8%; 3/16), or other unavoidable factors such as the wrong test being done, results not seen, misinterpretation of results or inexperienced staff (50.0%; 8/16—too few to report individually).
Figure 3: Delay in surgical diagnosis for NTASM patients who had an operation, 2019–2024
Cases with delays in surgical diagnosis
Note: n = 265
Source: Appendix E, Data Table 7
3.4.3 ASA class
Anaesthetists use the ASA physical status classification system to assess preoperative risk, based on a patient’s comorbidities and other factors. Classification levels range from grade I (normal healthy patient) to grade VI (declared brain-dead patient).5 NTASM surgeons should record the ASA grade for all patients, regardless of whether they receive an operation.
The median ASA grade for patients who had an operation was IV (patient with severe systemic disease that is a constant threat to life) (IQR III-IV), with 71.9% (187/260) classified grade IV or higher (Figure 4). Surgeons did not report ASA grade for 1.9% (5/265) of patients who had an operation.
Figure 4: ASA grade of NTASM patients who had an operation, 2019–2024
Abbreviation: ASA = American Society of Anesthesiologists. ASA grade I = a normal healthy patient, ASA grade II = a patient with mild systemic disease, ASA grade III = a patient with severe systemic disease, ASA grade IV = a patient with severe systemic disease that is a constant threat to life, ASA grade V = a moribund patient not expected to survive without the operation, ASA grade VI = a declared braindead patient whose organs are being removed for donor purposes
Note: n = 260, data missing n = 5
Source: Appendix E, Data Table 8.
3.4.4 Surgeon perception of risk status
Surgeons assess each patient’s risk of death. Risk of death, while subjective, reflects the complexity of the procedure in the context of the patient’s presentation, estimated physiological reserve and ASA grade. Surgeons assessed 70.7% (186/263) of patients as having a moderate or considerable risk of death before an operation (data missing n = 2). Death was expected for 16.7% (44/263) of patients who underwent at least one operation (Figure 5). This likely reflects surgical management within the context of care with palliative intent; whereby the goal is to manage symptoms (e.g. pain) and relieve suffering where possible.
Note: n = 263, data missing n = 2
Source: Appendix E, Data Table 9.
Figure 5: Surgeon-assessed risk of death for operative patients, 2019–2024
3.4.5 Consultant surgeon in theatre: operating, assisting or supervising
Consultant surgeons may be in theatre to perform, assist with or supervise an operation. The nature of the consultant presence in theatre depends on the treating surgeon comprehensively completing questions on the SCF relating to the operation. When patients have multiple operations performed by surgeons from different specialties, the treating surgeon (completing the SCF) is required to answer all operation questions.
A total of 434 operations were performed. The presence of a consultant surgeon in any capacity (i.e. performing, assisting with or supervising the operation) was 80.2% (348/434).
Consultants performed 59.0% (256/434) of operations, assisted in 9.0% (39/434) of operations or were present in theatre in an unspecified capacity for 12.2% (53/434) of operations (Figure 6). The frequency of consultants operating has remained above 50.0% across all years.
Consultant: Assist Consultant: In Theatre Consultant: Operate
Note: Consultant in theatre indicates a surgeon may have performed, assisted with or supervised the operation (not specified). n = 434
Source: Appendix E, Data Table 10.
Figure 6: Operations conducted with a consultant surgeon present in theatre, 2019–2024
Consultant surgeon presence in theatre (%)
3.4.6 Postoperative complications
Postoperative complications occurred in 19.1% (50/262) of patients. The frequency of postoperative complications has steadily decreased from 23.4% of all operations in 2020–2021 to 6.7s% in 2023–2024 (Figure 7 and Appendix E, Data Table 11).
A delay in recognising postoperative complications occurred in 10.0% (5/50) of patients who had a complication (data not shown).
Note: some patients had several complications. n = 262, data missing n = 3
Source: Appendix E, Data Table 11.
Figure 7: NTASM patients with operative complications, 2019–2024
Postoperative complications are listed by frequency of occurrence in Appendix E, Data Table 12. Surgeons did not report the type of complication for every patient. Some patients had several complications. The most frequently recorded complications were: procedure-related sepsis (14.6%; 7/48) significant postoperative bleeding (14.6%; 7/48) anastomotic leak (12.5%; 6/48) tissue ischaemia (6.3%; 3/48) endoscopic perforation (4.2%; 2/48).
3.4.7 Unplanned return to theatre
Unplanned returns to theatre are strong predictors of death. On average, 18.9% (50/265) of patients who died after an operation had an unplanned return to theatre (Table 10). Unplanned returns to theatre were lower in 2022–2023 and 2023–2024 compared with the 3 previous years.
Table 10: Unplanned return to theatre, 2019–2024 (n = 265)
3.5 Infections
Surgeons document whether patients died with a clinically significant infection present, and whether any infections were noted at the time of admission or developed during the hospital admission.
More than a third of NTASM patients (40.7%; 131/322, data missing n = 3) had a clinically significant infection present at the time of death. More patients acquired the infection before admission to hospital (54.6%, 71/130) than during admission (45.4%, 59/130) (data missing n = 1).
When the infection was acquired during admission, 13.6% (8/59) of patients acquired it preoperatively and 59.3% (35/59) acquired it postoperatively; 15.3% (9/59) had a surgical site infection and 11.9% (7/59) had an invasive infection at a different site (data not shown). Pneumonia was the most frequent type of infection acquired during admission (52.5%; 31/59) (Table 11).
Table 11: NTASM patients who acquired a clinically significant infection during admission, 2019–2024
Note: n = 59
The infective organism was identified for 55.0% of patients (71/129, data missing n = 2). Patients can be infected with multiple organisms, including bacteria, viruses and yeasts. More infections were due to bacteria than either yeasts or viruses. Staphylococcusaureus was the cause of most bacterial infections (Table 12).
Table 12: Most frequent microbial infections in NTASM patients, 2019–2024
3.6 Trauma
Surgeons are asked to document whether patients were admitted to hospital due to trauma and, if so, the cause of the trauma.
Nearly a quarter of patients (24.3%; 79/325) were admitted due to trauma. The most frequent causes of trauma were falls (59.5%; 47/79), traffic incidents (20.3%; 16/79) or violence (10.1%; 8/79).
The most frequent locations of falls were private homes 74.5% (35/47), hospitals 14.9% (7/47) and care facilities 6.4% (3/47). Other fall locations were places of sport, recreation, farming or work (Table 13). In the current report, the number of patients experiencing falls at home and in hospital increased compared to the 2023 report (35 vs 30 falls at home; 7 vs 5 falls in hospital).
Table 13: Location of trauma-causing fall, 2019–2024
Note: *Other includes sport, recreation, farm, work.
Of all traffic incidents, 93.8% involved either a motor vehicle (12/16) or a motorcycle (3/16). The number of pedestrians involved in traffic incidents was too few to report (Appendix E, Data Table 13).
Public violence (75.0%; 6/8) was the main cause of trauma-related violence.
4. PEER-REVIEW OUTCOMES
KEY POINTS
100% of audited cases received an FLA, 11.4% (37/325) received an SLA
62.2% (23/37) of SLAs were due to insufficient information
84.6% (275/325) of patients had no CMIs
72 CMIs were identified in 50 patients
35 serious CMIs were preventable
4.1 Second-line assessment
The peer-review process comprises a retrospective examination of the clinical management of patients who died while under the care of a surgeon. All assessors (first- and second-line) must decide whether the death was a direct result of the disease process alone or if aspects of patient management may have contributed to the outcome.
All cases undergo an FLA, where the first-line assessor decides whether the treating surgeon has provided enough information to allow an informed decision to be reached on the appropriateness of the case management. If inadequate information was provided or if further clarification is needed, the first-line assessor requests an SLA. During the auditing period, an SLA was requested for 11.4% (37/325) of cases, 62.2% (23/37) of which were due to insufficient information provided. This could be avoided by more comprehensive completion of SCFs by surgeons.
4.2 Deep vein thrombosis prophylaxis
Assessors report on whether a surgeon’s use or non-use of DVT prophylaxis was appropriate. Figure 8 shows assessors’ opinions on the appropriateness of DVT prophylaxis.
Abbreviation: DVT = deep vein thrombosis
Note: n = 324, data missing n = 1
Source: Appendix E, Data Table 14
Between 2019 and 2024, assessors indicated that the decision to use or withhold DVT prophylaxis was appropriate in 73.5% (238/324) of cases. In 1.9% (6/324) of cases, assessors reported there had been an inappropriate decision regarding the use or non-use of DVT prophylaxis. Assessors were unable to comment on the appropriateness of the DVT prophylaxis decision in 24.7% (80/324) of cases.
The percentage of assessors unable to comment on the appropriateness of DVT prophylaxis has increased over time, perhaps due to insufficient information being provided by the treating surgeon or within the medical notes.
4.3 Critical care unit usage
Assessors report on whether a decision not to treat a patient in ICU or a critical care unit (CCU) was appropriate and/or if the patient would have benefited from such treatment. The proportion of patients not treated in CCU and assessors’ opinions of ICU/CCU usage are shown in Table 14.
The percentage of patients not treated in ICU/CCU during 2022–2024 (37.7%; 26/69) and 2023–2024 (42.9%; 24/56) is higher than in previous years.
Assessors reported that 4.8% (5/104) of patients not treated in ICU would have benefited from ICU admission. The proportion was highest during 2020–2021, when assessors reported that 3 patients would have benefited from care in ICU or CCU but did not receive it.
Table 14: Deaths without admission to intensive
care or high dependency unit, 2019–2024
4.4 Clinical management issues
A primary objective of the peer-review process is to determine whether a patient’s death was a direct result of the disease process alone or if aspects of patient management might have contributed to the outcome. First- and second-line assessors consider whether areas of the care pathway could have been improved. Any CMIs identified are classified as: an area of consideration (lowest level of concern) an area of concern an adverse event (most serious level of concern).
CMIs reported are those from the highest level of assessment (i.e. from an SLA if one was performed). Most audited cases (84.6%; 275/325) had no reported CMIs.
A total of 72 CMIs were recorded in 15.4% of patients (50/325), indicating that a patient can have more than one CMI (data not shown). For patients with multiple CMIs, the most serious CMI was analysed for this report (Section 2.4).
CMIs were classified as an area of consideration for 9.2% of patients (30/325), an area of concern for 3.1% of patients (10/325) and an adverse event for 3.1% (10/325) of patients (data not shown).
4.4.1 Perceived impact of clinical management issues
Using a 3- or 4-point scale, first- and second-line assessors were asked to indicate:
1. What impact did any perceived issue of patient management have on the clinical outcome?
2. Was the issue preventable?
3. Which clinical team was responsible for the issue?
Table 15 shows the frequency of assessor-identified CMIs according to level of seriousness (consideration, concern, adverse event). Of the 50 most serious CMIs, assessors considered that 58.0% (29/50) may have contributed to the death of the patient, 26.0% (13/50) made no difference, and 16.0% (8/50) caused the death of a patient otherwise expected to survive.
Of the most serious CMIs, more than three quarters (74.5%; 35/47) were definitely or probably preventable, with 19.1% (9/47) considered definitely preventable (data missing n = 3).
CMIs can be associated with more than one clinical team. Assessors reported that more than half of the CMIs were associated with the surgical team (54.0%; 27/50).
the death of a patient otherwise
to survive
Preventability of CMI1
Associated clinical team2
Abbreviation: CMI = clinical management issue
Notes: n = 50
1Data missing n = 3. Not all assessors reported on preventability of CMIs.
2Some CMIs may be associated with more than one clinical team.
3Others includes nursing home, anaesthetics team, emergency department.
Table 15: Impact and seriousness of CMIs according to assessor, 2019–2024
4.4.2
Areas of consideration
Assessors classified 60.0% (30/50) of CMIs as areas of consideration. They considered that 56.7% (17/30) of these may have contributed to the death of the patient and 6.7% (2/30) caused the death of a patient otherwise expected to survive. These events were considered preventable in 60.0% (18/30) of these audited deaths. These preventable events were mostly associated with the surgical team (66.7%; 12/18). The most frequent preventable events were delay to surgery, better to have done a different operation or procedure, and inadequate assessment in 50.0% (9/18).
4.4.3
Areas of concern and adverse events
Assessors classified 40.0% (20/50) of CMIs as areas of concern or adverse events. Assessors considered that 60.0% (12/20) of these CMIs may have contributed to the death of the patient; 30.0% (6/20) caused the death of a patient otherwise expected to survive. These CMIs were considered preventable in 85.0% (17/20) of deaths with CMIs. These preventable events were mostly associated with the surgical team (52.9%; 9/17). The most frequent preventable events were:
postoperative care unsatisfactory, postoperative admission to ICU refused, fluid balance unsatisfactory, incorrect use of drains/catheters (35.3%; 6/17)
decision to operate; better to have performed a different operation, either more extensive or more limited (29.4%; 5/17).
delay to surgery, delay in diagnosis, missed diagnosis (23.5%; 4/17).
4.4.4
Preventable clinical management issues
Assessors classified 74.5% (35/47) of all CMIs as definitely or probably preventable. Of these CMIs, assessors considered that 51.4% (18/35) may have contributed to the death of a patient and 17.1% (6/35) caused the death of a patient otherwise expected to survive. These preventable CMIs were mostly associated with the surgical team (60.0%; 21/35). The most frequent preventable events were:
decision to operate; better to have performed a different operation, either more extensive or more limited (22.9%; 8/35)
missed diagnosis; delay to surgery, diagnosis, assessment, blood transfusion or recognising complications (31.4%; 11/35)
postoperative care unsatisfactory, postoperative admission to ICU refused, fluid balance unsatisfactory, incorrect use of drains/catheters (25.7%; 9/35).
5. ABORIGINAL AND TORRES STRAIT ISLANDER PERSONS
5.1
Overview
KEY POINTS
Aboriginal and Torres Strait Islander patients compared to non-Indigenous patients were: more likely to be younger than age 50 (on average 19 years younger) more likely to be female, be transferred and admitted to a public hospital more likely to have an operation if admitted under a general surgeon more likely to present to hospital with an infection similar regarding the presence of comorbidities.
Note: CMIs did not occur in 86.6% (103/119) of Aboriginal and Torres Strait Islander patients.
The RACS 2020 Indigenous health position paper reaffirms the College’s commitment to improving health outcomes for Aboriginal and Torres Strait Islander people.6
Aboriginal and Torres Strait Islander people in Australia experience poorer health outcomes compared with nonIndigenous people. The disease burden is 2 times higher in Aboriginal and Torres Strait Islander people than in nonIndigenous people. Contributing to this increased disease burden are CVD, cancer, musculoskeletal conditions, diabetes and chronic respiratory disease, with the rates increasing at a younger age in Aboriginal and Torres Strait Islander patients than in non-Indigenous patients.7,8 Adult Aboriginal and Torres Strait Islander people are more likely to have 3 or more comorbidities (38%) compared with adult non-Indigenous people (26%).8
Differences in patient characteristics between NTASM Aboriginal and Torres Strait Islander and non-Indigenous patients are shown in Table 16. Aboriginal and Torres Strait Islander NTASM patients are, on average, 19 years younger than non-Indigenous patients and 3 times more likely to be younger than 50 years of age. There was no statistical difference in the presence of 3 or more comorbidities between Aboriginal and Torres Strait Islander patients and nonIndigenous patients with comorbidities.
Aboriginal and Torres Strait Islander patients were nearly 3 times more likely to be transferred than were nonIndigenous patients. Aboriginal and Torres Strait Islander patients were more likely to present to hospital with an infection compared with non-Indigenous patients (Table 16).
Table 16: Clinical characteristics of NTASM Aboriginal and Torres Strait Islander and non-Indigenous patients, 2019–2024
Abbreviations: CI = confidence interval, IQR = interquartile range, RR = risk ratio, SD = standard deviation Notes: n = 325; Aboriginal and Torres Strait Islander patients n = 119 (36.6%), non-Indigenous patients n = 206 (63.4%). Denominator varies because not all questions were answered.
*Statistically significant at p<0.05 but may not be clinically significant. The lower the p value, the greater the statistical significance of the observed difference (Section 2.10)
The RR reference group is non-Indigenous patients. RR (alternatively called relative risk [Section 2.10]) is the risk of having the characteristic of interest in one group, divided by the risk of having the characteristic of interest in the reference group.
5.2 Age
The age-adjusted life expectancy gap (at birth) between Aboriginal and Torres Strait Islander people and nonIndigenous people is 8 years for males and 7 years for females. Life expectancy for Aboriginal and Torres Strait Islander people decreases by 6–7 years for those living in remote and very remote areas.7
For NTASM patients, the average age gap between Aboriginal and Torres Strait Islander patients and non-Indigenous patients is 19 years. Male Aboriginal and Torres Strait Islander patients were 21 years younger and female patients were 16.5 years younger than male and female non-Indigenous patients (Figure 9).
9: Median age of Aboriginal and Torres Strait Islander and non-Indigenous NTASM patients, 2019–2024
Age in years (median)
Aboriginal and Torres Strait Islander – Female
Aboriginal and Torres Strait Islander – Male
Non−Indigenous – Female
Non−Indigenous – Male
Note: n = 325
Source: Appendix E, Data Table 15
Figure
5.3 Comorbidities
Comorbidities remain higher in Aboriginal and Torres Strait Islander people than in non-Indigenous people. The AIHW report (July 2023) on changes in health status and outcomes for Aboriginal and Torres Strait Islander people reported that death rates due to CVD and kidney disease had decreased, death rates due to cancer had increased and death rates due to diabetes were unchanged.7
A comparison of comorbidities in NTASM Aboriginal and Torres Strait Islander patients and non-Indigenous patients is shown in Table 17. Aboriginal and Torres Strait Islander patients were 2 times more likely to have renal disease and diabetes. There was no significant difference in the presence of CVD between Aboriginal and Torres Strait Islander patients and non-Indigenous patients.
Table 17: Most frequent comorbidities in Aboriginal and Torres Strait Islander and non-Indigenous NTASM patients, 2019–2024
Abbreviations: CI = confidence interval, RR = risk ratio
Notes: n = 325; Aboriginal and Torres Strait Islander patients n = 119 (36.6%), non-Indigenous patients n = 206 (63.4%).
Patients often have more than one comorbidity; 1,010 comorbidities were reported for 282 patients.
*Statistically significant at p<0.05 but may not be clinically significant. The lower the p value, the greater the statistical significance of the observed difference (Section 2.10).
The RR reference group is non-Indigenous patients. RR [alternatively called relative risk (Section 2.10)] is the risk of having the characteristic of interest in one group, divided by the risk of having the characteristic of interest in the reference group.
5.4 Operations
Overall, Aboriginal and Torres Strait Islander patients were more likely to have an operation than were non-Indigenous patients. The number of operations that Aboriginal and Torres Strait Islander patients had was not related to any specific surgical specialty (Table 18).
Table 18: Admission of Aboriginal and Torres Strait Islander and non-Indigenous NTASM patients by surgical specialty and percentage who had an operation, 2019–2024
Abbreviations: CI = confidence interval, RR = risk ratio
Notes: n = 325; Aboriginal and Torres Strait Islander patients n = 119, non-Indigenous patients n = 206.
Specialities are not reported where patient numbers are fewer than 5.
*Other includes vascular, urology, plastic, otolaryngology head and neck, ophthalmology, obstetrics and gynaecology, oral/maxillofacial surgery.
The RR reference group is non-Indigenous patients. RR [alternatively called relative risk (Section 2.10)] is the risk of having the characteristic of interest in one group divided by the risk of having the characteristic of interest in the reference group.
5.5 Peer-review outcomes
Assessors found no significant difference in the operative care provided to Aboriginal and Torres Strait Islander patients and non-Indigenous patients (Table 19).
SLAs were completed for 13.4% (16/119) of Aboriginal and Torres Strait Islander patients compared to 10.2% (21/206) for non-Indigenous patients (RR 1.32; 95% CI 0.72 to 2.43) (data not shown).
Table 19: Assessor opinion on difference of care between NTASM Aboriginal and Torres Strait Islander and nonIndigenous patients who had an operation, 2019–2024 (n = 265)
Abbreviations: CI = confidence interval, RR = risk ratio
Notes: n = 265 NTASM patients who had an operation; Aboriginal and Torres Strait Islander patients n = 98, non-Indigenous patients n = 167.
Results to be treated with caution as numbers are low.
The RR reference group is non-Indigenous patients. RR [alternatively called relative risk (Section 2.10)] is the risk of having the characteristic of interest in one group divided by the risk of having the characteristic of interest in the reference group.
5.5.1
Clinical management issues
No CMIs were reported for most Aboriginal and Torres Strait Islander patients. The number of Aboriginal and Torres Strait Islander patients with no CMIs (86.6%; 103/119) is less than the number of non-Indigenous patients without CMIs (92.2%; 190/206). A total of 25 CMIs were reported for 16 Aboriginal and Torres Strait Islander patients (13.4%; 16/119). Only the most serious CMI per patient is included in the following analysis. Among the 16 patients with CMIs, assessors considered that 6.7% (8/119) of CMIs were areas of consideration, 2.5% (3/119) were areas of concern and 4.2% (5/119) were adverse events. Of these CMIs, 62.5% (5/8) of the perceived areas of consideration may have contributed to death, all (100.0%; 3/3) of the areas of concern may have contributed to the death and 60.0% (3/5) of the adverse events may have contributed to the death of the patient.
Of those patients who had an operation, 14.3% (14/98) had CMIs, compared with 9.5% (2/21) of patients among those who did not have an operation. For patients who had an operation, 42.9% (6/14) of CMIs were areas of consideration, 21.4% (3/14) were areas of concern and 35.7% (5/14) were adverse events. Of patients with assessor-identified CMIs considered to be areas of concern and/or adverse events, 7 CMIs were preventable and 2 caused the death of the patient.
6. NT BASELINE PATIENTS 2023
The NT Department of Health provides NTASM with baseline data from patients who had a surgical procedure in an NT public hospital and were discharged from hospital. The NT baseline data include patients admitted to all NT public hospitals between January and December 2023 who had a surgical procedure or operation that was performed by a surgeon and required a general anaesthetic. Patients may have been admitted by a physician or a surgeon. These data reflect the last admission for each patient and exclude patients reported to NTASM.
A total of 17,441 baseline patients were admitted between January and December 2023. Non-surgical obstetrics patients and those having non-surgical dental or allied health procedures (n = 4,615) were excluded from the comparison. The remaining 12,826 patients had a total of 15,220 admissions (ranging from 1 to 15 readmissions). Comparisons are based on the last admission of each patient only.
6.1 Characteristics of NT baseline and NTASM patients
The characteristics of NT baseline patients and NTASM patients admitted during the same period are presented in Table 20.
The proportion of Aboriginal and Torres Strait Islander patients compared with non-Indigenous patients was higher among NT baseline patients compared with NTASM patients. More NTASM patients had emergency admissions than baseline patients and the proportion of NTASM patients with comorbidities was nearly double that of baseline patients. The greatest difference was seen in the proportion of patients with diabetes, respiratory disease, renal disease, CVD and hepatic disease. The proportion of NTASM patients with ASA grade I–III was lower than for baseline patients.
A higher proportion of NT baseline patients had no comorbidities compared with NTASM patients (Table 21). Only 0.7% (90/12,826) of NT baseline patients had 5 or more comorbidities, compared with 27.1% (19/70) of NTASM patients.
Postoperative complications occurred in 5.0% of NT baseline patients compared with 11.4% (8/70) of NTASM patients. The most frequent complications were wound sepsis (1.9%), other complications (0.9%), haemorrhage (0.7%) and orthopaedic internal device (0.5%).
Trauma due to falls occurred in 6.5% (833/12,809) of NT baseline patients compared with 18.6% (13/70) of NTASM patients.
Table 20: Characteristics of NT baseline and NTASM patients, January to December 2023
Abbreviations: ASA = American Society of Anesthesiologists, IQR = interquartile range, NR = not recorded
Notes: ASA grade I = a normal healthy patient, ASA grade II = a patient with mild systemic disease, ASA grade III = a patient with severe systemic disease, ASA grade IV = a patient with severe systemic disease that is a constant threat to life, ASA grade V = a moribund patient not expected to survive without the operation, ASA grade VI = a declared brain-dead patient whose organs are being removed for donor purposes.
All NT baseline patients were discharged from hospital; all NTASM patients died in hospital.
Comorbidities and diagnoses for NT baseline data are provided by the NT Government with International Classification of Diseases codes (ICD-10). To enable comparison with NTASM data, NTASM recodes the ICD-10 categories to match those in the SCF.
*Number of patients and variables supplied with the baseline data was similar to that provided with the 2022 data.
**Dementia in NTASM patients is recorded as neurological.
6.2 Comorbidities
NTASM patients had a higher percentage of a total of 3 or more comorbidities compared to NT baseline patients (Table 21).
Table 21: Comorbidity frequency in NT baseline and NTASM patients, January to December 2023
6.3 Age
The age of NT baseline patients forms a normal distribution compared to a skewed distribution for NTASM patients. In general, NT baseline patients were younger than NTASM patients (Figure 10).
Note: Excludes 6 NT baseline patients and 1 NTASM patient age 95+ years
Source: Appendix E, Data Table 16
7. REFERENCES
1. Queensland Health, Statistical Services Branch. Queensland Hospital Admitted Patient Data Collection (QHAPDC): admission and separation date/time. State of Queensland (Queensland Health). 2017 [accessed 01 December 2023]. Available from: https://www.health.qld.gov.au/__data/assets/pdf_file/0026/656423/info-sheet-adm-sepv1.0.pdf
2. Mulvey HE, Haslam RD, Laytin AD, Diamond CA, Sims CA. Unplanned ICU admission is associated with worse clinical outcomes in geriatric trauma patients. J Surg Res. 2020 Jan; 245:13-21. doi: 10.1016/j.jss.2019.06.059. Epub 2019 Aug 5. PMID: 31394403. Available from: https://www.journalofsurgicalresearch.com/article/S00224804(19)30455-X/fulltext
3. Australian Institute of Health and Welfare. Table 6.3: Interventions reported for the 20 most common ACHI procedure blocks for overnight acute separations, public and private hospitals, 2019–20. [accessed 01 December 2023]. Available from: https://www.aihw.gov.au/getmedia/2b45b633-a499-4f8a-9d8c-45bb639926e9/6admitted-patient-care-2019-20-tables-procedures.xls.aspx
4. North J, Blackford F, Wall D, Allen J, Faint S, Ware R, et al. Analysis of the causes and effects of delay before diagnosis using surgical mortality data. Br J Surg. 2013;100(3):419–425. Available from: http://onlinelibrary.wiley.com/ doi/10.1002/bjs.8986/epdf
5. American Society of Anesthesiologists. ASA physical status classification system. Developed by ASA House of Delegates/Executive Committee [original approval 15 October 2014; updated 13 December 2020]. Available from: https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system
6. Royal Australasian College of Surgeons. Indigenous Health Position Paper June 2020. Available from: https://www.surgeons.org/-/media/Project/RACS/surgeons-org/files/interest-groupssections/indigenous-health/RACS-Indigenous-Health-Position-Statment-FINAL-July2020. pdf?rev=f3f6592c396240ff95d1e2181a3f9276&hash=7A6AA309F899C8171491E99489F228AB
7. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework: summary report July 2023. Canberra: AIHW. 2023 [accessed 01 December 2023]. Available from: https://www. indigenoushpf.gov.au/report-overview/overview/summary-report?ext=.
8. Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples: 2015, Cat. no. IHW 147.AIHW, Australian Government, accessed 01 December 2023. doi:10.25816/5ebcbd26fa7e4 [accessed 01 December 2023]. Available from: https://www.aihw.gov.au/reports/ indigenous-australians/indigenous-health-welfare-2015/contents/table-of-contents
8. APPENDICES
8.1 Appendix A: NTASM governance structure
Data Figure 1: NTASM governance structure
Ministers of health
Government departments of health
Participating hospitals
Consultant surgeons
RACS Council
RACS Professional Standards and Fellowship Services Committee
RACS Surgical Audit Committee
ANZASM Steering Committee
RACS Audit of Surgical Mortality Management Committee
Project staff
8.2 Appendix B: NTASM audit process
Data Figure 2: NTASM audit process
Audit of surgical mortality receives notification of death
Surgeon is noticed to complete the SCF via electronic Fellows Interface
SCF submitted by the surgeon
Assessor is notified to complete the FLA via electronic Fellows Interface
Feedback to surgeon
*Has a right of reply been lodged?
Case closed No
Feedback to surgeon
Case closed
Feedback to surgeon
Clinical management issues
Preventable Not Preventable No issues
Preventable clinical management issues (PCMI) form
Peer-review assessment evaluation form
Audit of surgical mortality aggregates and reports on returned data
Note: *When the treating surgeon receives a second-line assessment report, they have the right of reply and can request a second SLA. The clinical director will select a different assessor to review the case.
8.3 Appendix C: Surgeons report what they would have done differently Sample comments highlight the ability of surgeons to self-reflect and learn from experience.
ThepatientarrivedfromaCOVIDhotspot,thereweredelaysinthepatientbeingtransferredfrom ICUtotheatre.ProcessforfuturepatientswhoarrivefromCOVIDhotspotsorforthosewhomay have COVID should be streamlined.
1. Surgical case form (SCF): A structured questionnaire completed by the consultant surgeon associated with the case. Consultant surgeons enter SCF responses into a bespoke online database—the RACS Audit of Surgical Mortality Fellows Interface.
2. Anaesthetic case form: A structured questionnaire optionally completed by the anaesthetist associated with the case (anaesthetist participation is voluntary).
3. First-line assessment (FLA): Case assessment conducted by a surgeon from the same speciality as the consultant surgeon. The first-line assessor reviews the SCF (not patient files) and enters responses into the RACS Fellows Interface. The first-line assessor will either close the case or recommend further assessment by a second-line assessor.
4. Second-line assessment (SLA): Case assessment conducted by a surgeon from the same speciality as the consultant surgeon. Second-line assessors are generally specialists in the area under review. First- and second-line assessors respond to the same set of questions; however, SLAs are more in-depth and forensic because these assessors have access to all medical records. NTASM provides second-line assessors with a letter summarising the issues to be addressed in their report.
5. Cases may be referred for an SLA if: an area of concern or adverse event is thought to have occurred during the patient’s clinical care and warrants further investigation the patient’s death was unexpected (i.e. a healthy patient not expected to die) information provided by the consultant surgeon was insufficient to reach a conclusion in the FLA an SLA report could highlight aspects of surgical practice and provide an educational opportunity for the surgeon involved and/or a wider audience by publication as a case note review.
A surgeon can appeal the findings of an SLA, in which case the clinical director selects an additional independent second-line assessor. NTASM has had no occurrences of this to date.
6. Operation: refers to operations and procedures in this report (i.e. an operation may refer to a relevant radiological or endoscopic procedure as well as a surgical procedure).
7. Separation: the process by which an episode of care for an admitted patient is completed. A separation may be formal or statistical. An episode of care may be completed because the patient’s treatment is complete, the patient no longer requires care, the patient has died, the patient is transferred to another hospital/care facility or the patient leaves the hospital against medical advice.
8.5 Appendix E: Performance review data
Data Table 1:
Data Table 2: Notifications
Data Table 3: Sex ratio of NTASM patients by
Data Table 4: Age distribution of NTASM patients,
Abbreviations: IQR: Interquartile range, SD: Standard deviation
Data Table 5: Age of NTASM patients, 2019–2024 (n = 325)
Data Table 6: Most frequent comorbidities of NTASM patients, 2019–2024 (n = 282*)
Notes: 1,010 comorbidities reported for 282 patients; data missing n = 2. Patients often have more than one comorbidity. *Other includes alcohol abuse, anticoagulation therapy, arthritis/osteoporosis, dementia/Alzheimer disease, cerebral palsy, hyperthyroidism, malignancy, malnutrition/cachexia, peripheral vascular disease, smoking, ischaemic heart disease.
Data Table 7: Delay in surgical diagnosis for NTASM patients who had an operation, 2019–2024 (n = 265)
Data Table 8: ASA grade for NTASM patients who had an operation, 2019–2024 (n = 260*)
Abbreviation: ASA = American Society of Anesthesiologists
Notes: *Data missing n = 5
ASA grade I = a normal healthy patient, ASA grade II = a patient with mild systemic disease, ASA grade III = a patient with severe systemic disease, ASA grade IV = a patient with severe systemic disease that is a constant threat to life, ASA grade V = a moribund patient not expected to survive without the operation, ASA grade VI = a declared brain-dead patient whose organs are being removed for donor purposes.
Data Table 9: Surgeon-assessed risk of death for
Note: *Data missing n = 2
Data Table 10: Consultant surgeon presence in theatre, 2019–2024 (n = 434)
Data Table 11: Frequency of NTASM postoperative complications, 2019–2024 (n = 262*)
Note: *Data missing n = 3
Data Table 12: Type of postoperative complications in NTASM patients, 2019–2024 (n = 48*)
Note: *Data missing n = 2
Data Table 13: Road traffic incidents that caused trauma, 2019–2024 (n = 16)
Data Table 14: Assessor-perceived appropriateness of DVT prophylaxis, 2019–2024 (n = 324*)
Note: *Data missing n = 1
Data Table 15: Age and sex of NTASM Aboriginal and Torres Strait Islander and non-Indigenous patients, 2019–2024 (n = 325)
and Torres
Islander
Note: data presented as median age (years) and interquartile range
Data Table 16: Age of NT baseline and NTASM patients, January to December 2023
