The latest report of the Royal Australasian College of Surgeons’ (RACS) Western Australian Audit of Surgical Mortality (WAASM) shows that over the last two years there has been a notable rise in deaths in patients under the care of a surgeon in Western Australia (WA).

The standout observation in this year’s report is an increase in deaths in 2022, the second year this has occurred. The increase of 40–50 patients (approximately seven per cent) in each of the last two years is an abrupt reversal of the almost uninterrupted decline in deaths under a surgeon since WAASM commenced over 20 years ago. The number of deaths has reverted to that last seen in 2016.

The audit undertakes an independent, external clinical review of all patients who died while under the care of a surgeon. The reviews are conducted by surgeons who practice in the same specialty but are from a different hospital. The aim is ongoing improvement of surgical care.

WAASM Clinical Director, Dr James Aitken, noted that “While it is possible this increase represents annual variation, it is a large variation that has persisted over two years and is inconsistent with the previous long-term downward trend. An alternative explanation that has to be considered is that the increased mortality is a direct or indirect consequence of COVID-19”.

In WA, the number of reported COVID-19 infections throughout 2020 and 2021 was very small. There was a sharp increase in COVID-19 in early 2022 and the first death of a surgical patient with COVID-19 was reported to WAASM in March 2022. The increase was only seen following emergency admissions.

In 2022, WAASM documented 31 deaths in COVID-19 positive patients, slightly more than half the observed overall increase in deaths. While it is possible that WAASM did not capture all COVID-19 positive surgical patients who died, this difference raises the possibility that other, indirect, COVID-19-related factors may explain why the number of deaths was greater than the number infected. For example, more patients presenting as an emergency might have had poorly controlled medical co-morbidities secondary to a lack of routine community care or presented with more advanced disease that increased the surgical risk.

The 2022 WAASM Report noted that COVID-19 infection impacts microvascular circulation. Other conditions that have a similar impact (e.g. smoking, diabetes) are well known to be associated with greater surgical risk and poorer outcomes. The same is true if a patient’s immune system has been disturbed. There is now considerable scientific evidence to support this suggestion that previous COVID-19 infection has a long term sub-clinical impact.

The report suggests that it is possible that some deaths occurred in patients who were previously infected with COVID-19, but at the time of presentation, appeared fully recovered and asymptomatic and were managed under that assumption. However, if such patients had a hidden sub-clinical legacy of microvascular circulation or immune system impairment their surgical risk may, unknowingly, have been increased.”

Dr Aitken noted that “There is minimal data regarding surgical risk in post COVID-19 patients who have no symptoms of long COVID, indeed are asymptomatic. In mid-2023, the Australian Safety and Efficacy Register of New Interventional Procedures – Surgical published a review of the surgical risk for asymptomatic post COVID-19 patients. The review acknowledged the dearth of objective evidence. WAASM has recommended that surgeons should ascertain if patients have previously had COVID-19 and even in asymptomatic cases, consider the guidelines in the review”.

For further information, please see the WAASM 2023 Report Snapshot or the full WAASM 2023 Report on the RACS website. 
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