Measuring Perioperative Mortality: The Key to Improvement.

Anesthesiology, V 127 • No 2 215 August 2017 J OHN Snow was one of the founding fathers of anesthesia in the late nineteenth century and a pioneering epidemiologist. He recorded the details of more than 5,000 anesthetics during more than 12 yr of practice and stressed the importance of accurate drug administration and patient monitoring.1 In 1949, Mackintosh2 published an analysis of anesthetic deaths and discussed common lessons learned, such as safe positioning of unconscious patients, the appropriate use of thiopentone, and the dangers of cylinder misconnections. He encouraged the investigation of perioperative deaths as a means to improve anesthesia safety. In the modern era, Lunn and Devlin3 worked together as anesthesiologist and surgeon to examine the whole patient journey, recognizing that factors in anesthesia, surgery, and perioperative care required consideration if improvements in outcomes were to be made. Eichorn4 gathered data that supported mandatory standards for anesthetic monitoring, the basis of the American Society of Anesthesiologists standards and guidelines today.5 A recent meta-analysis and systematic review of perioperative mortality and anesthesiarelated deaths shows the positive impact of safety interventions over the past 80 yr.6 However, this article also suggests that improvements have not been matched in poorer parts of the world. Indeed, in countries with a low human development index (defined by life expectancy, education, and per capita income indicators), anesthesia mortality has remained unchanged since the 1950s.7 It is particularly refreshing therefore to read the work of Sileshi et al.8 in this edition of ANESTHESIOLOGY and their demonstration that it is possible to gather high-quality outcome data to improve anesthesia services in a middle-income country. Sileshi et al.8 developed a data collection tool to prospectively monitor perioperative mortality rate in a tertiary nongovernmental referral hospital in Kenya. They recorded 24-h, 48-h, and 7-day mortality, as well as case-specific perioperative data including type of surgery and anesthesia, American Society of Anesthesiologists status, and use of essential monitors and the World Health Organization Surgical Safety Checklist. The team at Kijabe recorded a lower perioperative mortality compared with other studies in lowand middle-income countries, and, importantly, they recorded an improvement in outcomes over the study period. Few anesthesiaand surgeryrelated deaths actually occur in the operating room. Although harm may start there, death often takes place on the ward or intensive care unit some days later. Timing of data collection is therefore important. Early (immediate) deaths within 24 h will describe those dying of overwhelming illness, anaphylaxis, total spinal, airway disaster, or cardiac arrest; later follow-up will detect those who were initially resuscitated from a catastrophic event and those developing multiorgan failure from sepsis, aspiration, and so forth. Data collection and follow-up of patients in a resource-constrained system are extremely difficult and therefore the measurement needs to be practical. Sileshi et al.8 are to be congratulated on their use of innovative methods to solve these challenges in data collection. The authors trained anesthesia providers to collect data electronically, which provided better returns than a traditional paper-based system. The system was designed to allow intermittent data upload to cope with irregular Internet connectivity. The authors found it difficult to capture 7-day follow-up, but since mobile phone technology is almost universal in Kenya, they used a local research officer to capture the 7-day information by phone. The hospital in Kijabe has pioneered the development nurse anesthesia training in Kenya and has developed a model of task sharing between physician and nurse providers. Their outcomes are likely to be due in part to external funding and Measuring Perioperative Mortality