SHORT COMMUNICATION

Anaesthesia Related Mortality in ASA-1 and 2 Patients as a

Quality Improvement Indicator
Mueen Ullah Khan1 and Fauzia Anis Khan2

ABSTRACT
Quality and safety in anesthesia is usually monitored by analysis of perioperative mortality-morbidity and incidents.
Clinical quality indicator, death within 48 hours of anaesthesia exposure is considered to be a flag that can alert to possible
problems in individual patient care. The measurement of perioperative mortality as a quality indicator is a continuous peer
reviewed quality improvement activity. Medical records and morbidity and mortality files were reviewed to see the trends
and finding the benchmark of mortality in ASA-1 and 2 patient who died between 1992-2006 within 48 hours of
anaesthesia exposure. Mortality in class 1 was nil. Anaesthetic mortality in ASA-1 and 2 patients was 0.35 per 10,000 and
0.74 per 10,000 of ASA-2 patient's volume. Anaesthesia-related mortality was 0.17 per 10,000 and 0.37 per 10,000 of
ASA-2 patient's volume which is almost double of the overall calculated incidence. We suggest continuing monitoring of
anaesthesia related mortality as a continuous quality indicator in developing countries. The reporting and analyzing of data
according to the ASA status volume should be taken as a denominator. The available benchmark will help in evaluating
the confounding factors and perioperative care of a particular group of patients.

Key words: Anaesthesia. Mortality. Quality indicator. Morbidity.

The role of an Anesthesia Quality Improvement Program
is to provide a routine, planned and systematic process
to monitor and evaluate the quality and appropriateness
of anesthesia care. Good clinical practice is a prerequisite
in order to provide quality of care. Measurement of
quality indicators is a continuous review of practice
against defined standards, established by peers and
comparison with norms of practice.1 Anaesthetic
mortality and serious morbidity is becoming exceedingly
rare but insight into the contribution of anaesthesia to
perioperative mortality is important to enable further
improvements in the safety and quality of perioperative
care. The reported incidence of mortality in American
Society of Anaesthesia (ASA) status-1 (normal healthy
patient) and 2 (patient with mild systemic disease)
patients range between 0.2-0.04 per 10,000.2 Analysis
of mortality in relatively healthy patients removes the
influence of patients disease and helps to focus on the
controllable system-related problems. This audit was
conducted to find out the historical benchmark of
mortality in ASA-1 and 2 patients in an university
hospital of South Asian country, any emerging trends
1 Department of Anaesthesia, King Saud University, Riyadh,
Saudi Arabia.
2 Department of Anaesthesia, The Aga Khan University Hospital,
Karachi.
Correspondence: Dr. Mueen Ullah Khan, Assistant Professor,
Department of Anaesthesia, King Khalid University Hospital,
King Saud University, P.O. Box 74800, Riyadh, Saudi Arabia.
E-mail: mueenullahpk@hotmail.com
Received April 03, 2010; accepted February 3, 2011.
over the years and to compare this benchmark with
other international data.
All surgical patients who died within 48 hours of
receiving anaesthesia during the audited years were
evaluated for demographic information, preoperative
condition, ASA status, level of anaesthetist, type of
surgery, duration of anaesthesia and surgery, time of
mortality and sequence of events in a predesigned form
by the primary consultant anaesthetist. All cases were
reviewed by two independent consultants not involved in
the management of the patient's care. They gave their
written opinion regarding the possible cause of death,
role of anaesthesia in mortality and whether the
mortality was avoidable. The role of anaesthesia was
further classified as solely, partially or not contributing to
the mortality.
The perioperative period was defined as the time from
the induction of anaesthesia to PACU discharge, ICU or
ward. Anaesthetic mortality in ASA-1 and 2 patients
was defined as deaths occurred within 48 hours of
anaesthesia between January 1, 1992 and December
31, 2006. Cardiothoracic surgeries were excluded.
Anaesthesia related deaths were defined as where
anaesthesia was solely responsible or partially
responsible for mortality. The anaesthesia factors that
were noted included the type of anaesthesia, duration of
anaesthesia and surgery and the presence of
anaesthesia consultant at the time of event. The time
and place of mortality, at induction, at maintenance and
at emergence were documented. Factors relating
anaesthesia, surgery, patient or combination of factors
and human factors responsible for mortality were
documented. Duration of anaesthesia was 9 hours.

234 Journal of the College of Physicians and Surgeons Pakistan 2011, Vol. 21 (4): 234-236
Anaesthetic mortality in ASA 1-2 patients
The total surgical workload handled by the department
of anaesthesia between 1992 and 2006 was 140,384
cases. A total of 56,153 ASA-1 (n=29220) and ASA-2
(n=26923) patients were anaesthetized during that
period. Two ASA-2 patients died within 48 hours of
receiving an anaesthetic during this period. No mortality
occurred in ASA-1 patients. Anaesthetic mortality in
ASA-1 and 2 patients, was calculated as 0.14
(2/140384) per 10,000 and anaesthesia related mortality
was 0.07 (1/140384) per 10,000.
The first case was of a 2 years old male in whom frontal
craniotomy for excision of tumour was performed as an
elective case under general anaesthesia. Duration of
anaesthesia was 9 hours. Patient had cardiac arrest
6-hours postoperatively in ICU due to raised ICP. On
peer review evaluation, the two reviewing consultants
agreed that the surgical factor, intracranial bleeding was
responsible for the mortality.
The second ASA- 2 patient was a 45 years old female
who presented with only stridor and diagnosis of vocal
cord paralysis, in whom emergency tracheal intubation
and direct laryngoscopy under general anaesthesia was
planned. She had cardiac arrest at induction and could
not be resuscitated. Tracheal intubation was difficult and
patient developed pnemothorax and surgical emphysema
probably due to the use of intubation stylet. Anaesthesia
was solely responsible for the mortality. Human error,
error of judgment, poor pre-operative evaluation and
lack of supervision were identified as factors that played
a part in the mortality. Overall anaesthetic mortality in
ASA-1 and 2 patients was calculated as 0.35 (2/56153)
per 10,000 and 0.74 (2/26923) per 10,000 of ASA-2
patient's volume. Anaesthesia related mortality was
calculated as 0.17 (1/56153) per 10,000 and 0.37
(1/26923) per 10,000 of ASA-2 patient’s volume.
There has been a lack of agreement on how to appraise
quality in anaesthesia. Various countries and research
groups differ widely in their criteria for reporting adverse
outcomes/ events.3 Lack of uniformity in operational and
outcome definitions in the reported anaesthesia
literature is a major issue.
Monitoring of anaesthetic mortality as a continuous
outcome quality indicator in relatively healthy patients
(ASA 1-2) provide a quantitative basis for anaesthetist,
organizations, and planners aiming to achieve improve-
ment in care and the processes by which patient care is
provided.
The process of benchmarking is used to measure
efficacy and allow organizations or departments to
develop plans for improvements or adopt best practice
within their own subspecialty. In spite of relative safety of
modern anaesthesia mortality related to anaesthesia
can still occur. The causes related to anaesthetic morbidity
have been identified,4 but study populations may differ
Journal of the College of Physicians and Surgeons Pakistan 2011, Vol. 21 (4): 234-236
historically and regionally with respect to perioperative
risks,which makes it difficult to detect trends.
Monitoring the anaesthetic mortality in relatively healthy
individuals serve to document the quality of care,
benchmarking, make judgments and set priorities.
Reviewing and analysis of anaesthetic mortality in
healthy individuals provide us the opportunity for
identifying the confounding factors other than patient's
health. Therefore, if fair comparisons in anaesthetic
mortality as outcome between well equipped hospital
and hospitals with limited facilities are to be made
components that relate to the medical care system
should be isolated.
With the changing practice in anaesthesia, same day
admissions, complexity of anaesthetic care, the
increasingly complex equipment has increased
demands and expectations from the anaesthetist.
However, anaesthetists are dealing with an increasing
number of patients who may undergo increasingly
extensive and prolonged surgical interventions.
Therefore, an increase in morbidity and death rates may
be expected. There are therefore strong indications to
continue the monitoring of anaesthetic mortality
according to the ASA status. The continuous monitoring
and analysis of anaesthetic mortality as an indicator in
ASA-1 and 2 patients helps in identifying the system
related factors and problems with training and supervision.
Trends at the study centre show that about forty percent
of total anaesthetics administered are ASA-1 and 2
patients. In this study the bench mark for anaesthetic
mortality in ASA-1 patients comes out as zero. However,
two ASA-2 patients died during this period. After peer
review of the anaesthesia related mortality, the level of
anaesthesia supervision in cases with expected airway
problem was raised and availability of surgeon ready for
emergency tracheostomy was made mandatory. Data
shows that the overall mortality rate in this study is
comparable to any reported incidence5 but if
denominator is taken from a particular group of patients
(ASA-1 and 2) the figure is almost double of the reported
incidence. We suggest continuing anaesthetic mortality
monitoring as a continuous quality indicator at
departmental level and at large. The said figures can be
used as benchmark for reporting of anaesthesia related
mortality according to the volume of respective ASA
status, which will help in evaluating the perioperative
care and systems geared with the type of patients
without other confounding variable of patient disease.
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Mueen Ullah Khan and Fauzia Anis Khan

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236 Journal of the College of Physicians and Surgeons Pakistan 2011, Vol. 21 (4): 234-236