Health Systems Action

Death after Surgery is the Third Biggest Cause of Mortality – and a Public Health Problem

In 1954, Henry Beecher, the pioneering American anaesthesiologist, described death from anaesthesia as a “public health problem“. Seventy years later, thanks to concerted effort and innovation, anaesthesia is about 100 times safer, occurring in about 1 in 100,000 cases. This makes surgery safer and contributes to its popularity and effectiveness: globally, over 313 million surgical procedures (2015 estimate) are done each year.

But there’s still a public health problem. Postoperative death in the 30 days after surgery has become the third leading cause of mortality, after heart disease and stroke, accounting for 7.7% of all global deaths, 4.2 million in total. This is nearly a thousand times more likely than an anaesthesia-related death. Thus, a surgical procedure can technically be a success yet far too commonly end in a tragic outcome.

What’s the explanation? What can be done?

Complications drive harm and mortality

Surgical complications such as infections, heart and respiratory problems, bleeding and blood clots, are the main drivers of post-surgical mortality. Only a small minority are fatal but overall complications are startlingly common, occurring in association with one in every six elective operations and one in four inpatient procedures. They are also very costly. A 2012 US study found that a single surgical complication extended hospital stay an average of 2.5 days, and increased costs by over $6,000. Each additional one roughly doubled the additional costs and time spent in hospital.

Reducing the frequency and severity of surgical complications should therefore be a priority for any health system. Doing so can begin by gaining a better understanding of three issues: (1) patient and operation characteristics, (2) certain predictable effects of surgery on the body, and (3) one particular aspect of postoperative care.

1. Patient and operation characteristics

Surgical patients tend to be older and to have more health problems[1],[2] than the general population, a trend that’s increasing. More patients who are frail are having surgery; this includes minor procedures, such as eye surgery for cataracts, which generally go well, but also complex, invasive operations with serious risk of harm even when technical success is achieved.

2. Stress of surgery

Major surgery is in effect a major injury and as such triggers responses, including inflammation, that stress vital body systems including the heart, lungs, kidneys, brain, immunity and blood clotting systems leading to predictable decreases in health and function (Figure 1) that last days or weeks.

After surgery, in patients with less “reserve” or resilience, these changes can affect the heart, showing up as heart muscle damage, or even a heart attack; the lungs, with pneumonia, or partial lung collapse; reduced kidney function or kidney failure; blood clots; altered mental status; and infection associated with lowered immunity.

Figure 1. The trajectory (purple line) of a high risk patient’s response to and recovery from major surgery. Impact on several body systems creates vulnerability to complications (shaded area, below the blue line) and, at the extremes (below the red line), potentially, to organ failure. Return to preoperative levels of health and function does not always occur. Adapted from Lee et al and Bernard Riedel, Melbourne.

3. Postoperative care

In most hospital wards, vital signs (heart rate, blood pressure, breathing rate, oxygen levels, state of consciousness) and patient status are checked by bedside nurses every 4 to 6 hours. This extended interval can allow serious changes to go undetected, with potentially devastating effects such as delayed detection of a heart attack, sepsis (severe infection) or breathing problems.

Image: Freepik

Three key processes for changing outcomes, preventing harm and death.  

In the face of these challenges, three key processes offer significant opportunities for improved outcomes: preoperative risk estimation and sharing, “prehabilitation”, and postoperative care and monitoring

1. Risk estimation and information sharing

This is about assessing and communicating important patient risk factors.

In the hours or days before an elective surgical procedure, surgeons, anaesthesiologists, nurses and other professionals assess the patient. When things go well, these assessments are shared with the entire surgical team before the operation. Everyone is “on the same page”, facilitating decision-making and communication of the best possible surgical care plan.

However, preoperative assessment may occur in an inconsistent or uncoordinated manner on an abbreviated timeline and without reliable links to needed action, such as adjusting medications, correcting anaemia, deciding on intensive care unit admission, or modifying anaesthetic and pain management choices.

Formal scores, scales and well-defined care steps can enhance this process. For example, South African anaesthesiologists recently developed a consensus-based set of 81 screening questions intended for preoperative administration by nurses. Defined “critical risk factors”, such as a recent heart attack or shortness of breath, lead to specialist evaluation before the day of surgery.

Along with a standardised form of assessment, other validated tools can be used to detect, measure and share key actionable risk factors, including:

Risk models populated with local data and updated continuously are likely to be more useful than fixed models developed somewhere else, particularly if they enable not only mortality predictions but also the likelihood of specific complications such as heart problems or blood clots so preventive action, for example ICU admission, or administration of blood thinning medicine, can occur reliably.

Extremes of risk sometimes necessitate reconsideration of the decision for surgery. Patients should receive comprehensive risk-benefit information. Shared decision-making helps ensure that potential benefits of surgery outweigh the risks and that treatment aligns with patient preferences, values, and needs.

Image: DALL-e

2. Prehabilitation

Prehabilitation is about enhancing patient resilience before surgery

Short-term programmes of improved nutrition, regular exercise, and psychological support collectively known as prehabilitation, can boost patient outcomes including mortality. Adding other targeted interventions such as enrolment in smoking cessation can add further benefit.

Effective medical management can reduce morbidity and mortality in patients with chronic disease, and the same is true for patients undergoing surgery. Optimising underlying conditions such as heart disease, diabetes and anaemia preoperatively is required. Two to six weeks may be sufficient time for specific programmes to increase resilience (Figure 2) and lower the chance of complications.

Figure 2. The patient’s health trajectory (purple line) with a programme of preoperative interventions (“prehabilitation”) – e.g., dietary support, prescribed physical activity, psychological support – that given sufficient time to take effect can increase resilience to the stress of surgery. The improved margin of reserve keeps health and function above the threshold (blue line) where complications occur and (red line) organs fail. Adapted from Lee et al and Bernard Riedel, Melbourne

3. Enhanced postoperative monitoring

This is about improving vigilance and early problem detection.

Cardiac issues, respiratory complications, and bleeding are leading causes of postoperative death. Close monitoring of vital signs for early detection of these and other threats is crucial for preventing serious patient harm.

Early Warning Systems” are protocols to detect and respond to early signs of impending patient deterioriation still limited by the intermittent nature of nursing observations and data collection and the task burden of nurses and other team members. Technology might help.

Even without special technology, including AI, improvement in detecting and treating post-surgery complications is still possible. For example, vital sign charts can be redesigned to visually flag out-of-range values and to do away with unnecessary figures and writing that inhibit easy appreciation of significant change. Nurses can be trained to evaluate changes and promptly respond, supported by a strong hospital safety culture, to escalate care. Patients at risk can be moved to more visible locations in the ward.

How do the best performing surgical teams reduce surgical risk and complications?

High levels of variation and significant performance gaps between hospitals highlight several opportunities for learning and improvement.

Here are six things high-performing surgical teams can do:

Schedule cases to allow time for assessment and optimisation, avoiding the expediency of scheduling high risk patients or surgeries in the next available operating theatre slot. Knowing that proper measurement of risk and management of chronic conditions is time well spent rather than an inconvenient delay, teams build these activities into the first phase of perioperative care, 2-6 weeks before surgery.

Work as a team. Proper preoperative assessment requires a collaborative effort from surgeons, anaesthesiologists, and colleagues including nurses in theatre and the ward, as well as pharmacists, physiotherapists, various medical specialists and others. For continuity of care, GPs have an important role, and nurse Care Coordinators, such as in ERAS programs, make invaluable contributions to safety, efficiency and kind, compassionate care.

Develop preoperative clinics. A “one-stop-shop” where all involved healthcare professionals see patients, collaborate closely and develop plans for patients and for their system, is ideal: convenient for patients, and for comprehensive team-based pre-surgical evaluation, preparation, and decision making.

Educate and involve patients and families in the surgical care process, such as through “surgery camp” sessions that foster active participation and which have been shown to improve patient experience and outcomes.

Invest in improvement and learning, for example using evidence-based guidelines such as those from the ERAS Society. They understand that implementation is a collective effort that’s not instantaneous and seldom straightforward. Actionable steps are for individual patients but also for system-wide care process improvement.

Measure outcomes such as mortality, complications, patient-reported outcomes, and costs. These metrics help reveal the underlying perioperative care processes, their effectiveness and the impact of change.


Despite major advances in surgery and anaesthesia, postoperative death is surprisingly common and a significant global public health issue. Fortunately, there is real potential to reduce deaths and harm through attention to patient risk factors, implementing prehabilitation (nutritional support, physical activity, psychological support and education), and better postoperative monitoring.

Targeting a 10% reduction in surgical complications could lead to a substantial decrease in local and global morbidity and mortality and could be a priority for health systems especially in low- and middle-income countries like South Africa.

[1] In the UK (2015), 22.9% of surgical patients were over age 75.

[2] In the US (2019), patients in the NSQIP database had an average age of 57, 15% had diabetes and the average BMI was 30. Source: International Journal of Surgery 109(9):2631-2640

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