The Lothian Surgical Audit (LSA) was inaugurated in Edinburgh as a mortality audit by Professor Sir James Learmonth (1895-1967) in 1946. Taking the form of a confidential peer review, regular meetings were held on Saturday mornings for Edinburgh surgeons to meet and discuss the reasons for patient deaths.
Learmonth took his inspiration for these meetings from the mortality conferences held at the Mayo Clinic in Rochester, Minnesota where he was researching under a Rockefeller Fellowship in the late 1920s. During these conference meetings, surgical deaths were scrutinised behind closed doors, and while open accountability was undoubtedly uncomfortable for many taking part, such rigorous enquiry encouraged and supported the surgical excellence underpinning the Mayo. Learmonth returned to Scotland in 1932, and by 1942 held both surgical Chairs in Edinburgh. At the close of the Second World War, Learmonth was concerned with demobilised soldiers returning to Edinburgh, who, despite having gained significant practice in battlefield injuries, had little experience in civilian surgery, and importantly, academic discipline and standards. It was against this backdrop that he looked back to the Mayo conferences, and initiated similar, closed-session meetings in his Edinburgh University Department of Clinical Surgery based in wards 7/8 of the Royal Infirmary.
Learmonth extended the meetings to include all the surgical units in the Royal Infirmary of Edinburgh and those in other hospitals in the Lothians. These meetings provided an opportunity for Edinburgh surgeons - junior and senior - to assemble once a week on Saturday mornings for discussion and scrutiny of general surgery units presenting data and reports on mortality. Initial participants were those representing ‘core’ clinical surgery units which took part in the Edinburgh emergency receiving rota, the units of the Royal Infirmary of Edinburgh, Eastern General Hospital, Leith Hospital and Western General Hospital (WGH) together with Bangour General Hospital. Other surgical units contributing were those at Bruntsfield, Deaconness and Longmore (the Southern Group), with Chalmers Hospital presenting jointly with the unit based at wards 15/16 of the Royal Infirmary with which it was linked. As the Saturday Morning Meetings progressed, developments saw the net being cast more widely, with the addition of other specialities at the meetings, which included: Diagnostic Radiology, Combined medical-surgical Gastro-intestinal unit (WGH), Orthopaedics, Neurosurgery, Paediatrics, Plastic Surgery, Radiotherapy, Cardio-thoracic Surgery, Urological Surgery and latterly Liver Transplant.
The Saturday Morning Meetings had a standard format, which was relatively unchanging from those initiated by Learmonth in 1946 until those held in the 1990s. The bulk of each meeting was devoted to research presentations, usually given by a trainee surgeon. This was designed to foster research and improve presentation skills. Each unit would prepare in advance of the meeting a handout showing their statistics for the year. These would include the number and type of operations and the number of deaths. This handout would also include a detailed list of all deaths in the unit, with patient identifiers removed. The table would typically list the events leading up to death and the reasons for the death. In presenting these a few were selected where death was unexpected or where different decisions might have prevented a fatal outcome. These would be discussed in detail. Any member of the audience was free to ask about any death on the handout. Combined meetings with Glasgow surgeons were held from time to time, but these were a forum for presentation of research papers and deaths were not discussed. As the importance of surgical audit was appreciated, separate Mortality Conferences were held. These were devoted to discussion of operative deaths and how these might be prevented, and the conferences produced summaries and recommendations.
While the general structure of Saturday Morning Meetings remained unchanging, there was a considerable shift in focus with the advent of new computer technologies and thus greater scope for more effective methods of data retrieval and analysis. In the earlier years of the Audit, data was recorded and presented at meetings with the aid of a theatre book, paper, pen and punch card. From the 1980s, computerised audit was introduced and every participating unit was eventually supplied with an audit computer. The implementation of LSA operation codes and surgical classification dramatically improved methods of recording operations and ultimately, more accurate data. Between 1983 and 1995, data was gathered for over 300, 000 operations.
The development of innovative computer packages designed for surgical audit were fundamental to the success of LSA; they enabled surgeons to move beyond the emphasis on mortality and address morbidity, and other more varied facets of surgical practice came under the spotlight. Moreover, the software was developed to accommodate different activities. For instance, change in treatments and the consequent impact on staffing, the numbers, training and skills required of surgeons, and work statistics gathered were used to help administrative policies with particular respect to consultant workloads. Importantly, development of specialist surgical computer packages came from the users themselves, i.e. surgeons, as opposed to information technology experts.
Greater formalisation of audit and a comprehensive pool of standardised and accurate data emerging from the computerisation process led the way for annual reports, commentaries and the mortality conferences to be introduced to LSA, offering greater analysis of regional trends and particular operations. Evaluation of these trends prompted major changes in the practice of surgery. For instance, high dependency units were introduced in light of the evidence from the Saturday Morning Meetings annual reports. Advances in the specialisation of vascular surgery was a further consequence, with LSA highlighting that patients with ruptured abdominal aortic aneurysms under the care of general surgeons showed a twice greater rate of mortality than those admitted to general surgeons.
The purpose of LSA was ultimately to promote high standards of surgical care and practice through education at the Saturday Morning Meetings, and also to accurately record statistics of surgical activity. In 1989, a Government White paper lauded the success of the Lothian Surgical Audit in its paper ‘Working with Patients’, and its principles were used as an illustration and proposed model for future clinical audits. The previous year a parallel study the Scottish Mortality Study had been instigated, which took LSA as its model, with the hope that peer review mortality audit would spread across all surgical specialities and across Scotland. By 1994, this objective was fully realised, with the Scottish Audit of Surgical Mortality (SASM) firmly in place in Lothian and the South East, and this became a national audit (LSA had essentially evolved into SASM). SASM is supported by the Royal College of Anaesthetists, Royal College of Physicians and Surgeons of Glasgow and the Royal College of Surgeons, Edinburgh, and was adopted and modified in Perth, Australia. The LSA additionally influenced the Scottish Trauma Audit Group (STAG), established in 1994.
It is important to note that the surgeons themselves were careful to take ownership of the Audit, (although latterly ownership was controversially taken over by Government), and the names of RCSEd Fellows appear throughout its history. In 1996, the 50th Anniversary of LSA was celebrated with a Symposium.
Individuals who made significant contributions to the Lothian Surgical Audit include: James Aitken, Professor Sir Patrick Forrest, Anthony ‘Tony’ Gunn, Tom McNair, Steve Nixon, Rosamund Gruer, Professor Vaughan Ruckley (first Chairman) and Molly Stewart.
- Interview between RCSEd Archivist and Iain Macintyre, August 2014 (See LSA 3/3. Macintyre is a past Vice President of the Royal College of Surgeons of Edinburgh and was a key participant in the Lothian Surgical Audit);
- J. Aitken, S. J. Nixon, C. V. Ruckley, ‘Lothian Surgical Audit: a 15 year experience of improvement in surgical practice through regional computerised audit’, The Lancet, Vol. 350 (1997), 800-04;
- Molly M. Stewart (ed.), Lothian Surgical Audit, 50th Anniversary Symposium Proceedings(The Scottish Office and National Health Service in Scotland, 1996).