Comparative surgical audit to monitor quality of care should be performed with a risk-adjusted scoring system rather than using crude morbidity and mortality rates. A validated and widely applied risk adjusted scoring system, P-POSSUM (Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality) methodology, was applied to a prospective series of predominantly general surgical patients at the Sarawak General Hospital, Kuching over a six months period. The patients were grouped into four risk groups. The observed mortality rates were not significantly different from predicted rates, showing that the quality of surgical care was at par with typical western series. The simplicity and advantages of this scoring system over other auditing tools are discussed. The P-POSSUM methodology could form the basis of local comparative surgical audit for assessment and maintenance of quality care.
BACKGROUND: The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is an objective and appropriate scoring system for risk-adjusted comparative general surgical audit. This score was devised in the UK and has been used widely, but application of POSSUM to centres outside the UK has been limited, especially in developing countries. This prospective study validated its application in a surgical practice with a different population and level of resources.
METHODS: All general surgical patients who were operated on under regional or general anaesthesia as inpatients over a 4-month period at Sarawak General Hospital in 1999 were entered into the study. All data (12 physiological and six operative factors) were analysed for mortality only with the POSSUM equation and the modified Portsmouth POSSUM (P-POSSUM) equation. Comparisons were made between predicted and observed mortality rates according to four groups of risk: 0-4, 5-14, 15-49 and 50 per cent or more using the 'linear' method of analysis.
RESULTS: There were 605 patients who satisfied the criteria for the study. Some 56.7 per cent of patients were in the lowest risk group. The POSSUM predictor equation significantly overestimated the mortality in this group, by a factor of 9.3. The overall observed mortality rate was 6.1 per cent and, again, the POSSUM predictor equation overestimated it at 10.5 per cent (P < 0.01). In contrast, the observed and predicted mortality rates for all risk groups, including the predicted overall mortality rate of 4.8 per cent, were comparable when the P-POSSUM predictor equation was used.
CONCLUSION: The POSSUM scoring system with the modified P-POSSUM predictor equation for mortality was applicable in Malaysia, a developing country, for risk-adjusted surgical audit. This scoring system may serve as a useful comparative audit tool for surgical practice in many geographical locations.
This paper presents an ultralow profile, low passive intermodulation (PIM), and super-wideband in-building ceiling mount antenna that covers both the cellular and public safety ultra high frequency (UHF) band for distributed antenna system (DAS) applications. The proposed antenna design utilizes a modified 2-D planar discone design concept that is miniaturized to fit into a small disc-shaped radome. The 2-D planar discone has an elliptical-shaped disc monopole and a bell-shaped ground plane, a stub at the shorting path, with asymmetrical structure and an additional proximity coupling patch to maximize the available electrical path to support the 350 MHz band range. The proposed design maximizes the radome area with a reduction of about 62% compared to similar concept type antennas. Besides, the proposed design exhibits an improved radiation pattern with null reduction compared to a typical dipole/monopole when lies at the horizontal plane. A prototype was manufactured to demonstrate the antenna performance. The VSWR and radiation pattern results agreed with the simulated results. The proposed antenna achieves a band ratio of 28.57:1 while covering a frequency range of 350-10,000 MHz. The measured passive intermodulation levels are better than -150 dBc (2 × 20 Watts) for 350, 700 and 1920 MHz bands.