The South African Surgical Outcomes Study: A 7-day prospective observational cohort study

Non-cardiac surgical morbidity and mortality is a major global public health burden. Sub-Saharan African perioperative outcome data are scarce. South Africa (SA) faces a unique public health challenge, engulfed as it is by four simultaneous epidemics: (i) poverty-related diseases; (ii) non-communicable diseases; (iii) HIV and related diseases; and (iv) injury and violence. Understanding the effects of these epidemics on perioperative outcomes may provide an important perspective on the surgical health of the country. To investigate the perioperative mortality and need for critical care admission in patients undergoing inpatient non-cardiac surgery in SA. A 7-day national, multicentre, prospective, observational cohort study of all patients ≥16 years of age undergoing inpatient non-cardiac surgery between 19 and 26 May 2014 at 50 public sector, government-funded hospitals in SA. The study included 3 927/4 021 eligible patients (97.7%) recruited, with 45/50 hospitals (90.0%) submitting data that described all eligible patients. Crude in-hospital mortality was 123/3 927 (3.1%; 95% confidence interval (CI) 2.6 - 3.7). The rate of postoperative admission to critical care units was 255/3,927 (6.5%; 95% CI 5.7 - 7.3), with 43.5% of admissions being unplanned. Of the surgical procedures 2,120/3,915 (54.2%) were urgent or emergency ones, with a population-attributable risk for mortality of 25.5% (95% CI 5.1 - 55.8) and a risk of admission to critical care of 23.7% (95% CI 4.7 - 51.4). Most patients in SA's public sector hospitals undergo urgent and emergency surgery, which is strongly associated with mortality and unplanned critical care admissions. Non-communicable diseases have a larger proportional contribution to mortality than infections and injuries. However, the most common comorbidity, HIV infection, was not associated with in-hospital mortality. The study was registered on ClinicalTrials.gov (NCT02141867).