Operation of VCCAMM

Page contents: Confidentiality | Data Collection | Validity of Data | Uniformity of Coronial Legislation | National Survey on Anaesthetic Mortality | Relationship with Specialist Organisations | Output of the Council | Terminology | Classification System

Under the auspices of the Victorian Department of Human Services the Council meets monthly and discusses the cases of mortality and morbidity prepared by the Chairman. The functions of the Council are to identify avoidable causes of morbidity or mortality related to anaesthesia (in most cases multifactorial) rather than to assess individual fault, and to disseminate as widely as possible the results of deliberations and possible strategies for prevention. The principal function is a quality assurance process rather than a clinical audit.

Confidentiality

It is emphasised that strict confidentiality is maintained at all times. The Council is very conscious of the fact that reporting of mortality and morbidity is voluntary and that the speciality of anaesthesia has a long history of participation in both audit and quality assurance activities. Victorian anaesthetists are generous in their co-operation and it is essential that their confidence is maintained by the Council having in place very strict protocols for the handling of information provided.

The Consultative Council is listed as a prescribed Council under the Health (prescribed Consultative Council) regulations 1986 and the provisions of the Health Act 1958 (amended 1995). Sections 24 and 24A prohibit any disclosure of information, which would lead to the identification of a person from whom or in relation to whom the information was obtained. Thus no personal information of any kind may be released by any present or past member of Council to any authority under any circumstances unless authorised by both the Minister for Health and the reporting doctor. The Council believes that the processes in place for maintenance of confidentiality are secure. No breaches of confidentiality have been reported to the Council or been the subject of any complaint. All members of the Council are convinced that proper evaluation of all factors leading to death or morbidity can only be completed if there is the possibility of direct communication between the Chairman and the doctor concerned.

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Data Collection

In Victoria direct reporting to the Council of mortality and morbidity related to anaesthesia is voluntary. Information is obtained by the Chairman from direct reports by anaesthetists and other medical practitioners. Some hospital quality assurance committees also provide information and a system is in place whereby the identity of patient and hospital is codified and the Chairman can contact the quality assurance co-ordinator if further information is required. The Chairman also has access to the Coroner's files which are public documents and the Council uses these files to gather further information, as necessary, from direct discussions with the anaesthetist or surgeon or by reviewing appropriate sections of the hospital record and by obtaining autopsy reports. It is emphasised that while the Council is advantaged by the cooperation of the State Coroner's Office, the Coroner does not have access to reports received by the Council or to the views of the Council.

After complete de-identification, the cases are presented to Council for discussion and classification. In the case of direct referrals the opinions of the Council are then conveyed to the medical practitioner concerned. Minutes of meetings are retained and all relevant data are entered into a secure and dedicated computer programme. There is no information in the computer database that identifies patient, doctor or hospital. Information is then analysed for major reports, information bulletins, teaching and responses to requests from medical practitioners. The process is slow but secure lines of communication must be maintained and the Council has a policy of avoiding publication of data on cases not finalised by the Coroner. This may mean a two-year delay.

Validity of Data

The level of voluntary reporting has increased since the previous report. The Council believes that information from voluntary reports and the obligatory reports to the Coroner along with follow-up with anaesthetists provides sufficient information to draw some reasonable conclusions and justify certain recommendations. However the total number of cases reported to Council do not completely reflect the true picture of mortality and morbidity in Victoria. In Western Australia, where mandatory reporting to Council is legislated, in the triennium 1994-96 the number of deaths classified per million of population was 238. This contrasts with a rate of 53 per million in Victoria and 145 per million for New South Wales. Thus, while the Council believes that it has assessed most cases of anaesthetic related mortality, there has to be concern about the reliability of the reporting system.

At present there is no information available to Council on total numbers of anaesthetics given in Victoria, and consequently no accurate mortality rate can be provided. In contrast, the Consultative Council on Obstetric and Paediatric Mortality and Morbidity, as a result of having an accurate denominator and mandatory reporting, has been able to report on data which provide international benchmarks on infant and maternal mortality rates. Unfortunately anaesthetic mortality committees in Australia, which have been world leaders in undertaking an audit of outcomes, currently have no valid epidemiological data to support claims about what we believe is the very high level of safety of anaesthesia in Australia.

However, following representations from this Council and the Australian and New Zealand College of Anaesthetists, the National Centre for Classification in Health has revised the current Australian Coding Standard on Anaesthesia and, from July 2000, anaesthetics will be captured on the hospital inpatient database. This will represent a significant advance for proper analysis of data.

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Uniformity of Coronial Legislation

The present Victorian legislation for reporting deaths associated with anaesthesia is confusing and less satisfactory than in all other Australian States. Many doctors are unsure when death associated with anaesthetic-related procedures should be reported. Junior staff are frequently left to report cases and to complete the Coronial deposition and as a result the amount of information provided to the Coroners is substandard.

This Council believes that for deaths associated with anaesthesia both anaesthetist and surgeon (or proceduralist) should be required to provide information to the Coroner. In addition the definition of an anaesthetic for the purpose of reporting to the Coroner should be expanded to identify the changing role of anaesthetists in providing regional and general anaesthesia, sedation, resuscitation and pain management. Moreover provision of anaesthesia is no longer restricted to operative surgery but is involved in an over expanding range of complex interventional procedures performed outside the operating theatre. These circumstances must be included in any audit of mortality or morbidity.

National Survey on Anaesthetic Mortality

Under the sponsorship of the Australian and New Zealand College of Anaesthetists the Chairmen of the State Consultative Councils have been appointed to the Mortality Committee of the College and have pooled the available data from all states to provide a national report. The first report covered the years 1991-93 (1) and the 1994-6 report has just been released. This most recent report (2) reviews the 135 deaths attributable partly or wholly to anaesthesia and, based on an approximate figure on the numbers of anaesthetics administered in Australia each year, assesses the mortality rate in the order of one death per 65,000 procedures. In Victoria, based on the same calculation, the rate for 1993-96 is one death per 62,000 procedures. In considering anaesthetic mortality in healthy patients or those with minor disability only, the rate is calculated as one death per estimated two million procedures, which compares very favourably with all other published figures.

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Relationship with Specialist Organisations

The Council receives strong support from both the Australian and New Zealand College of Anaesthetists (ANZCA) and the Australian Society of Anaesthetists (ASA). The Chairman attends meetings of the Victorian Regional Committee of the ANZCA which provides assistance in publicising the activities of the Council and also is invaluable in facilitating distribution of the Information Bulletins issued by the Council.

The ANZCA also provides the very considerable support for the National Mortality Committee, chaired by the President, and comprising the chairmen of the State Councils. A new initiative in 1999 has been the extension of the Maintenance of Professional Standards Programme of the ANZCA to recognise that a report to Consultative Councils which is of sufficient detail merits qualification for 3 points. In Victoria, to avoid compromising confidentiality, the Chairman provides the anaesthetist concerned confirmation of eligibility for points in a separate letter from the response to the report.

Output of VCCAMM

The major reports of the Council have a wide distribution, not only to anaesthetists, but to all medical practitioners in Victoria as well as to hospital administrators, learned colleges and other health care personnel.

• Regular information bulletins are also issued one or two times per year to all Victorian anaesthetists to impart information the Council perceives as needing rapid promulgation, particularly in relation to new techniques, equipment or drugs. Prior to 1998 these were sent to specialist anaesthetists only but the circulation now also includes rural general practitioner anaesthetists. These bulletins have been well received and have succeeded in highlighting a number of new problems.

• The Chairman represents the Council at monthly meetings of the Victorian Regional Committee of the ANZCA and raises issues of concern which are published in the regular newsletters of the Regional Committee, sent to all Victorian Fellows of the College and also publicised in the national bulletins of the ANZCA.

• The Chairman is the Victorian representative on the Mortality Committee of the ANZCA and provides the Victorian data for the National Mortality Report as well as participating in meetings and discussions on major issues and future strategies in relation to anaesthetic mortality.

• With the introduction of a sophisticated computer programme the Chairman and members of Council can now respond rapidly to specific enquiries from medical practitioners and contribute to teaching and discussions at medical meetings both in the city and, in particular, in rural centres.

On this occasion a report covering the years 1993-96 is produced but henceforth, to retain consistency with the National Report on Anaesthetic Mortality sponsored by the ANZCA, it is proposed that there should be triennial reports and that the regular bulletins with more recent information continue to be distributed.

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Terminology

While there is lack of uniformity in the definition of anaesthesia, this Council is of the opinion that modern anaesthesia encompasses the use of a sedative, analgesic, local or general anaesthetic drug or any combination of these. Thus the Council has considered a number of events relating to peri-operative care (e.g. acute pain management).

Anaesthesia Related Mortality

Anaesthesia related mortality is defined as a death which occurs during an operation or procedure (or within 24 hours of its completion) performed with the assistance of sedative, analgesic, local or general anaesthetic drugs or any combination of these, or, a death which may be the result (either partially or totally) of an incident during or after such operation or procedure even if more than 24 hours has elapsed since its completion.

Anaesthesia Related Morbidity

Morbidity is defined as any event related to an anaesthetic procedure which causes a life-threatening incident, temporary or permanent disability or significant distress. Morbidity is categorised as major or minor according to outcome. Please refer to Suggested List for Reporting to Council for more information.

Critical Incident:

A critical incident is identified as any incident which did, or could if not detected in time, effect patient safety. The Council does not specifically collect critical incidents although inevitably some such incidents are reported and these are included although it is recommended that these be directed to the Australian Incident Monitoring Study (AIMS).

Classification System

The VCCAMM utilises a detailed classification system that also identifies causal and/or contributory factors. Download the classification system below:

Anaesthesia Mortality & Morbidity Glossary of Terms - Case Classification (88kb, pdf)

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