The Registration of Complications in Surgery: A Learning Curve

What can they expect? Decreased quality of life and increased postoperative complication rate in patients with a fracture-related infection

BACKGROUND

By gaining insight into the Quality of Life (QoL) status and occurrence of complications, critical facets in the care for patients with Fracture-Related Infection (FRI) can be mitigated and measures can be taken to improve their outcome. Therefore, the aims of this study were to 1) determine the QoL in FRI patients in comparison to non-FRI patients and 2) describe the occurrence of other complications in both FRI and non-FRI patients.

METHODS

An ambidirectional cohort study was conducted in a level 1 trauma centre between January 1st 2016 and November 1st 2021. All patients who underwent surgical stabilisation of an isolated long bone fracture were eligible for inclusion. To avoid confounding, only patients with an Injury Severity Score (ISS) <16 were included. Data regarding patient demographics, fracture characteristics, treatment, follow-up and complications were collected of both non-FRI and FRI patients. QoL was assessed through the use of five-level EuroQol five-dimension (EQ-5D-5L) questionnaires twelve months post-injury.

RESULTS

A total of 134 patients were included in this study, of whom 38 (28%) FRI patients and 96 (72%) non-FRI patients. In comparison to non-FRI patients, FRI patients scored significantly worse on the QoL assessment regarding the index value (p = 0.012) and the domains mobility (p<0.001), usual activities (p = 0.010) and pain/discomfort (p = 0.009). Other postoperative complications were more often reported (p<0.001) in FRI patients (66%, n = 25/38) compared to non-FRI patients (27%, n = 26/96). During the median follow-up of 14.5 months (interquartile range (IQR) 9.5-26.5), 25 FRI patients developed a total of 49 distinctive complications besides FRI. The complications nonunion (18%, n = 9/49), infection other than FRI (e.g. line infection, urinary tract infection, pneumonia) (18%, n = 9/49) and implant failure (14%, n = 7/49) were the most frequently described in the FRI group.

CONCLUSION

Patients who suffered from an FRI have a decreased QoL in comparison to those without an FRI. Moreover, patients with an FRI have a higher rate of additional complications. These findings can help in patient counselling regarding the potential physical and mental consequences of having a complicated course of recovery due to an infection.

The Impact of Implementation of Palliative, Non-Operative Management on Mortality of Operatively Treated Geriatric Hip Fracture Patients: A Retrospective Cohort Study

(1) Background: Hip fracture patients with very limited life expectancy can opt for non-operative management (NOM) within a palliative care context. The implementation of NOM in the palliative context may affect the mortality of the operatively treated population. This retrospective cohort study aimed to determine whether the operatively treated geriatric hip fracture population would have a lower in-hospital mortality rate and fewer postoperative complications after the introduction of NOM within a palliative care context for patients with very limited life expectancy. (2) Methods: Data from 1 February 2019 to 1 February 2022 of patients aged 70 years or older were analyzed to give a comparison between patients before and after implementation of NOM within a palliative care context. (3) Results: Comparison between 550 patients before and 485 patients after implementation showed no significant difference in in-hospital or 1-year mortality rates (2.9% vs. 1.4%, p = 0.139; 22.4% vs. 20.2%, p = 0.404, respectively). Notably, post-implementation, fewer patients had prior dementia diagnoses (15% vs. 21%, p = 0.010), and intensive care unit admissions decreased (3.5% vs. 1.2%, p = 0.025). (4) Conclusions: The implementation of NOM within a palliative care context did not significantly reduce mortality or complications. However, NOM within palliative care is deemed a more patient-centered approach for geriatric hip fracture patients with very limited life expectancy.

The results of concentration of care: Surgical outcomes of neuroblastoma in the Netherlands

INTRODUCTION

In the Netherlands pediatric oncological care for solid tumours is concentrated in one centre since November 2014. One of the most frequently diagnosed solid non-brain tumours in children is the neuroblastoma. Results of surgical treatment of neuroblastoma since the start of this centralization are presented and compared to a historic cohort.

METHODS

The new national cohort of neuroblastoma (n = 111) consists of all consecutive patients treated between January 1st^, 2015 and April 1st^, 2021. The historic neuroblastoma cohort consists of all operated neuroblastoma patients in the Netherlands between 1998 and 2014 (n = 244). Intra-operative complications and surgical outcome were registered. Post-operative complications were divided in short (<30 days after surgery) and long term (>30 days). The severity of complications was graded using the Clavien Dindo Classification (CDC) system.

RESULTS

Intraoperative outcomes showed significant differences in favour of the new cohort with less blood loss (p < 0.001), fewer vascular complications (p < 0.001) and shorter duration of surgery (p < 0.001). Short term complications were comparable in numbers, but significantly more patients had CDC grade 3/4/5 complications in the historic cohort (p = 0.005). Long term complications did not differ. Estimated overall survival showed a better survival in the new cohort (log rank 0.022).

CONCLUSION

Centralization of care for neuroblastoma patients has led to a significant improvement of both intraoperative outcomes and short term complications.

International comparison of variation in performance between hospitals for THA and TKA: Is it even possible? A systematic review including 33 studies and 8 arthroplasty register reports

In order to improve care for total hip and knee arthroplasties (THA/TKA), hospitals may want to compare their performance with hospitals in other countries. Pooling data across countries also enable early detection of infrequently occurring safety issues. We therefore aimed to assess the between-hospital variation and definitions used for revision, readmission, and complications across countries.

PubMed, Embase, Web of Science, Cochrane library, Emcare, and Academic Search Premier were searched from January 2009 to August 2020 for studies reporting on: (i) primary THA/TKA; (ii) revision, readmission, or complications; and (iii) between-hospital variation. Most recent registry reports of Network of Orthopedic Registries of Europe members were also reviewed. Two reviewers independently screened records, extracted data, and assessed the risk of bias using the Integrated quality Criteria for the Review Of Multiple Study designs tool for studies and relevant domains for registries. We assessed agreement for the following domains: (i) outcome definition; (ii) follow-up and starting point; (iii) case-mix adjustment; and (iv) type of patients and hospitals included.

Between-hospital variation was reported in 33 (1 high-quality, 13 moderate-quality, and 19 low-quality) studies and 8 registry reports. The range of variation for revision was 0–33% for THA and 0–27% for TKA varying between assessment within hospital admission until 10 years of follow-up; for readmission, 0–40% and 0–32% for THA and TKA, respectively; and for complications, 0–75% and 0–50% for THA and TKA, respectively. Indicator definitions and methodological variables varied considerably across domains.

The large heterogeneity in definitions and methods used likely explains the considerable variation in between-hospital variation reported for revision, readmission, and complications , making it impossible to benchmark hospitals across countries or pool data for earlier detection of safety issues. It is necessary to collaborate internationally and strive for more uniformity in indicator definitions and methods in order to achieve reliable international benchmarking in the future.

Perioperative Complications after Parotidectomy Using a Standardized Grading Scale Classification System

Perioperative complications after parotidectomy are poorly studied and have a potential impact on hospitalization stay. The Clavien–Dindo classification of postoperative complications used in visceral surgery allows a recording of all complications, including a grading scale related to the severity of complication. The cohort analyzed for perioperative complications is composed of 436 parotidectomies classified into three types, four groups, and three classes, depending on extent of parotid resection, inclusion of additional procedures, and pathology, respectively. Using the Clavien–Dindo classification, complications were reported in 77% of the interventions. In 438 complications, 430 (98.2%) were classified as minor (332 grade I and 98 grade II), and 8 (1.8%) were classified as major (grade III). Independent variables affecting the risk of perioperative complications were duration of surgery (odds ratio = 1.007, p-value = 0.029) and extent of parotidectomy (odds ratio = 4.043, p-value = 0.007). Total/subtotal parotidectomy was associated with an increased risk of grade II-III complications (odds ratio = 2.866 (95% CI: 1.307–6.283), p-value = 0.009). Median hospital stay increased moderately in patients with complications. Use of Clavien–Dindo classification shows that parotidectomy is followed by a higher rate of perioperative complications than usually reported. Almost all complications are minor and have limited consequence on hospital stay.

Taking Morbidity and Mortality Conferences to a Next Level: The Resilience Engineering Concept

OBJECTIVE

To explore possibilities to improve morbidity and mortality conferences using advancing insights in safety science.

SUMMARY BACKGROUND DATA

Mortality and Morbidity conferences (M&M) are the golden practice for case-based learning. While learning from complications is useful, M&M does not meet expectations for system-wide improvement. Resilience engineering principles may be used to improve M&M.

METHODS

After a review of the shortcomings of traditional M&M, resilience engineering principles are explored as a new way to evaluate performance. This led to the development of a new M&M format that also reviews successful outcomes, rather than only complications. This "quality assessment meeting" (QAM) is presented and the first experiences are evaluated using local observations and a survey.

RESULTS

During the QAM teams evaluate all discharged patients, addressing team resilience in terms of surgeons' ability to respond to irregularities and to monitor and learn from experiences. The meeting was feasible to implement and well received by the surgical team. Observations reveal that reflection on both complicated and uncomplicated cases strengthened team morale but also triggered reflection on the entire clinical course. The QAM serves as a tool to identify how adapting behavior led to success despite challenging conditions, so that this resilient performance can be supported.

CONCLUSIONS

The resilience engineering concept can be used to adjust M&M, in which learning is focused not only on complications but also on how successful outcomes were achieved despite ever-present challenges. This reveals the actual ratio between successful and unsuccessful outcomes, allowing to learn from both to reinforce safety-enhancing behavior.

Patient reporting of complications after surgery: what impact does documenting postoperative problems from the perspective of the patient using telephone interview and postal questionnaires have on the identification of complications after surgery?

OBJECTIVES

To identify the frequency of postoperative complications, including problems identified by patients and complications occurring after discharge from hospital. To identify how these impact on quality of life (QoL) and the patient's perception of the success of their treatment.

DESIGN

Data from three prospective sources: surgical audit, a telephone interview (2 weeks after discharge) and a patient-focused questionnaire (2 months after surgery) were retrospectively analysed.

SETTING

Dunedin Hospital, Dunedin, New Zealand.

PARTICIPANTS

Of the 500 patients, 100 undergoing each of the following types of surgeries: anorectal, biliary, colorectal, hernia and skin.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were complications and the 36-item Short Form Health Survey (SF-36). Secondary outcomes included the patient's ratings of their treatment and a questionnaire-derived patient satisfaction score.

RESULTS

226 patients reported a complication; there were 344 separate complications and 411 reports of complications (16% of complications were reported on more than one occasion). The audit, telephone interview and questionnaire captured 12.6%, 36.3% and 51% of the 411 reports, respectively. Patients with complications had a lower SF-36 Physical Composite Summary (PCS) score (48.5 vs 43.9, p=0.021) and a lower Patient Satisfaction Score (85.6 vs 74.6, p<0.001). Rating of information received, care received, symptoms experienced, QoL and satisfaction with surgery were all significantly worse for patients with complications. On linear regression analysis, surgical complications, American Society of Anaesthesiologists score and age all made a similar contribution to the SF-36 PCS score, with standardised beta coefficients between 0.19 and 0.21.

CONCLUSIONS

Following surgery, over 40% of patients experienced complications. The QoL and satisfaction score were significantly less than for those without complications. The majority of complications were diagnosed after discharge from hospital. Taking more notice of the patient perspective helps us to identify problems, to understand what is important to them and may suggest ways to improve perioperative care.

Higher incidence of surgery-related complications in Wilms tumor nephrectomy from clinical records analysis compared with central database registration

BACKGROUND/OBJECTIVES

Central database registrations are widely used tools for assessment of clinical results, but their reliability is subject to debate. The aim of this study is to evaluate the reliability of central database registration for Wilms tumor (WT) nephrectomy-related complications.

DESIGN/METHODS

All Dutch patients undergoing WT nephrectomy according to the International Society of Paediatric Oncology (SIOP) 2001 protocol between 2001 and 2013 were evaluated. Results from the central database were analyzed and compared with data found via individual medical records analysis (gold standard).

RESULTS

A total of 179 patients were included. Fourteen (7.8%) patients with a total of 17 complications were identified in the central database. The medical records revealed that 33 (18.4%) of patients had undergone a total of 41 complications (P < 0.001). Operative complications were similar between the groups (P = 0.157). Eleven short-term complications were noted in the central database versus 27 in the medical records (P = 0.059). Significantly more long-term complications, namely, adhesive small-bowel obstruction, were noted from the medical records compared with the central database (7 vs 1, respectively, P < 0.001). Postoperative chemotherapy was significantly delayed by on average 6 days (P < 0.0001) in patients with complications. No significant effect of complications on event-free survival, overall survival, or the relapse rate was recorded.

CONCLUSION

Central database registrations underestimate the incidence of surgery-related complications after WT nephrectomy and need to be regarded with caution.

Systematic review of hospital-wide complication registries

Background

An institutional registry covering all surgical specialties could be an implementation tool in quality benchmarking between hospitals and aid determination of their cost‐effectiveness. The objective of this systematic literature review was to evaluate original articles on existing prospective surgical registries that can be used by single institutions across surgical specialties.

Method

A systematic review of the literature using PRISMA guidelines was conducted for articles focusing on hospital‐wide surgical registries. Single‐specialty retrospective registries, non‐defined outcome measures or system protocols, and studies not in English were excluded.

Results

Five articles were included for analysis. Evaluation of the articles revealed wide methodological heterogeneity in the classification and categorization of complications and data collection methods.

Conclusion

Ideal surgical quality monitoring systems should be real‐time, contain patient‐related risk factors, and encompass all surgical specialties. At present, such institutional registries are rarely reported and no consensus exists on their standard definitions and methodology.

Effects of esketamine sedation compared to morphine analgesia on hydrostatic reduction of intussusception: A case-cohort comparison study

BACKGROUND

Hydrostatic or pneumatic reduction of intussusception is an invasive procedure that is stressful and may be painful for a child. Resistance of the child may increase the duration of the procedure and decrease success rate of reduction. Analgesia can help to reduce pain, but not necessarily resistance. General anesthesia increases success rate of reduction. However, it requires the presence of an anesthesiologist, and may lead to anesthesia-related complications. Procedural sedation with esketamine could be a safe alternative.

AIM

The aim of this study was to compare hydrostatic reduction using morphine analgesia compared to procedural sedation with esketamine in terms of success rate, adverse events, and duration of reduction.

METHODS

A retrospective case-cohort comparison study was performed with two groups of patients who had undergone hydrostatic reduction for ileocolic intussusception and received morphine analgesia (n = 37) or esketamine sedation (n = 20). Until July 2013, reduction was performed after intravenously administered morphine. Hereafter, a new protocol for procedural sedation was implemented and reduction was performed after administration of esketamine. Cases were matched for age and duration of symptoms.

RESULTS

No adverse events requiring intervention other than administration of oxygen were reported for either group. Success rate of reduction using esketamine sedation was 90% vs 70% using morphine analgesia, risk ratio (RR) 1.29, 95% CI[0.93-1.77]. Recurrence rate using esketamine sedation was 10% vs 15% using morphine analgesia, RR 0.67, 95% CI[0.12-3.57]. Reduction time was shorter using esketamine sedation (Median 5 minutes, IQR 9 minutes) vs morphine analgesia (Median 8 minutes, IQR 16 minutes, P = .04, Median difference 3, 95% CI[-1.50-8.75]). Median hospital stay in the esketamine group was 1.5 days (IQR 1.8) vs 2 days (IQR 5.3) in the morphine group.

CONCLUSION

No serious adverse events were recorded. In comparison to morphine analgesia, with esketamine there was weak evidence for a higher success rate, lower recurrence rate, shorter duration, and shorter length of hospital stay.

[Comparison of the "Trigger" tool with the minimum basic data set for detecting adverse events in general surgery]

INTRODUCTION

Surgery is a high risk for the occurrence of adverse events (AE). The main objective of this study is to compare the effectiveness of the Trigger tool with the Hospital National Health System registration of Discharges, the minimum basic data set (MBDS), in detecting adverse events in patients admitted to General Surgery and undergoing surgery.

MATERIAL AND METHODS

Observational and descriptive retrospective study of patients admitted to general surgery of a tertiary hospital, and undergoing surgery in 2012. The identification of adverse events was made by reviewing the medical records, using an adaptation of "Global Trigger Tool" methodology, as well as the (MBDS) registered on the same patients. Once the AE were identified, they were classified according to damage and to the extent to which these could have been avoided. The area under the curve (ROC) were used to determine the discriminatory power of the tools. The Hanley and Mcneil test was used to compare both tools.

RESULTS

AE prevalence was 36.8%. The TT detected 89.9% of all AE, while the MBDS detected 28.48%. The TT provides more information on the nature and characteristics of the AE. The area under the curve was 0.89 for the TT and 0.66 for the MBDS. These differences were statistically significant (P<.001).

CONCLUSIONS

The Trigger tool detects three times more adverse events than the MBDS registry. The prevalence of adverse events in General Surgery is higher than that estimated in other studies.

Incidence and significance of postoperative complications occurring between discharge and 30 days: a prospective cohort study

BACKGROUND

Accurate documentation of complications is fundamental to clinical audit and research. While it is established that accurate diagnosis of surgical site infection (SSI) requires follow-up for 30 days; for other complications, there are minimal data quantifying their importance between discharge and 30 days.

METHODS

In this prospective cohort study, inpatients undergoing general or vascular surgery were reviewed daily for complications by the medical team and a research fellow. A standardized telephone questionnaire was performed 30 days following surgery. All complications were documented and classified according to severity.

RESULTS

A total of 237 of 388 patients who completed the telephone survey developed a complication, including 77 who developed a complication for the first time after discharge from hospital. Overall 135 (33%) of a total of 405 complications were identified after discharge. These complications included 36 of 63 (57%) SSI, 6 of 12 small bowel obstructions, and three of four major thromboembolic events and a number of space SSI, urinary infections, functional gastrointestinal problems, and pain management problems. Cardiac, respiratory, and neurologic complications were mainly diagnosed in hospital. Of the 135 "postdischarge" complications, 89 were managed in the community and 46 (34%) resulted in admission to hospital, including seven which required a major intervention. There was one death.

CONCLUSIONS

One-third of complications occurred after discharge, and one-third of these resulted in readmission to hospital. Research and audit based on inpatient data alone significantly underestimates morbidity rates. Discharge planning should include contingency plans for managing problems commonly diagnosed after discharge form hospital.

Trigger tool versus verbal inventory to detect surgical complications

Purpose

Traditionally, registering complications after surgery is based on voluntary reporting or incident reports. These methods may fail to detect the total number of complications. A trigger tool was developed to detect complications in hospitalized surgical patients. In this diagnostic study, we compared its sensitivity and specificity with the verbal inventory by surgical staff and residents.

Methods

A set of 31 potential triggers was chosen based on a systematic review and availability in hospital databases. The trigger tool was developed using multivariable regression and Receiver Operating Characteristic (ROC) analyses. A reference standard consisted of 300 patients, 150 with and 150 without complications. Sensitivity and specificity of the trigger tool and verbal inventory were determined.

Results

The final trigger tool consisted of nine triggers. Sensitivities of the trigger tool and verbal inventory were 70.7 vs. 78.7 %, respectively, while specificities were 70.0 vs. 100.0 %, respectively. Sensitivity values to detect major complications were 97.2 vs. 80.6 %, respectively.

Conclusions

The proposed customized trigger tool for a university hospital to detect surgical patients with complications appeared as accurate as a verbal inventory and even more accurate to detect major complications.

Developing a Registry for Complications in Otorhinolaryngologic Surgery: Tonsil Surgery as a Pilot Cohort

OBJECTIVE

To find a suitable method to prospectively register all tonsil surgery-related complications.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

From September 2011 to February 2012, patients undergoing tonsillectomy or tonsillotomy were enrolled. A wide range of demographic and clinical data including incidents of postoperative complications was recorded prospectively, and patient records were reviewed 9 months after the end of study period. We evaluated the coverage of prospective data recording, analyzed the complication rates, and assessed the process of registration.

RESULTS

A total of 573 patients were recruited. The study registry including 57 variables required the completion of missing data before analysis. Of all 79 patients with a complication, 69.6% were captured prospectively at the emergency department, and the rest were found when reviewing the patient records. The proportion of prospectively captured complications was highest for the most common complications (eg, 81.1% for secondary hemorrhage). The overall complication rate was 13.8%. Secondary hemorrhage was the most common complication, with the incidence of 9.6%.

CONCLUSION

We have demonstrated the initial feasibility of a prospective complication registry for otorhinolaryngology procedures, and the results can be applied accordingly. We also present 5 practical recommendations when initiating a functional registry. Particular attention should be paid to recognition and registration of both rare and serious events. Regular analysis of the results is required in order to respond to possible changes in the incidence or nature of complications.

Fatal surgical or procedure-related complications: a Finnish registry-based study

INTRODUCTION

In Finland, all healthcare personnel must be insured against causing patient injury. The Patient Insurance Centre (PIC) pays compensation in all cases of malpractice and in some cases of infection or other surgical complications. This study aimed to analyze all complaints relating to fatal surgical or other procedure-related errors in Finland during 2006-2010.

MATERIALS AND METHODS

In total, 126 patients fulfilled the inclusion criteria. Details of patient care and decisions made by the PIC were reviewed, and the total national number of surgical procedures for the study period was obtained from the National Hospital Discharge Registry.

RESULTS

Of the 94 patients who underwent surgery, most fatal surgical complications involved orthopedic or gastrointestinal surgery. Non-surgical procedures with fatal complications included deliveries (N = 10), upper gastrointestinal endoscopy or nasogastric tube insertion (N = 8), suprapubic catheter insertion (N = 4), lower intestinal endoscopy (N = 5), coronary angiogram (N = 1), pacemaker fitting (N = 1), percutaneous drainage of a hepatic abscess (N = 1), and chest tube insertion (N = 2). In 42 (33.3 %) cases, patient injury resulted from errors made during the procedure, including 24 technical errors and 15 errors of judgment. There were 19 (15.2 %) cases of inappropriate pre-operative assessment, 28 (22.4 %) errors made in postoperative follow-up, 23 (18.4 %) cases of fatal infection, and 11 (8.8 %) fatal complications not linked to treatment errors.

CONCLUSION

Fatal surgical and procedure-related complications are rare in Finland. Complications are usually the result of errors of judgment, technical errors, and infections.

Accuracy of administrative and clinical registry data in reporting postoperative complications after surgery for oral cavity squamous cell carcinoma

BACKGROUND

The purpose of this study was to describe and compare how postoperative complications after oral cavity squamous cell carcinoma (SCC) surgery are reported in medical records, institutional billing claims, and national clinical registries.

METHODS

The medical records of 355 previously untreated patients who underwent surgery for oral cavity SCC at our institution were retrospectively reviewed for postoperative complications. Information was compared with claims and National Surgical Quality Improvement Program (NSQIP) data.

RESULTS

We identified 219 patients (62%) experiencing 544 complications (10% major). Billing claims identified 29% of these patients, 36% of overall complications, and 98% of major complications. Of overlapping patients, NSQIP identified 27% of patients, 33% of overall complications, and 100% of major complications noted on chart abstraction.

CONCLUSION

The incidence of minor postoperative complications after oral cavity SCC surgery is relatively high. Both claims data and NSQIP accurately recorded major complications, but were suboptimal compared to chart abstraction in capturing minor complications.

Error rates in a clinical data repository: lessons from the transition to electronic data transfer--a descriptive study

OBJECTIVE

Data errors are a well-documented part of clinical datasets as is their potential to confound downstream analysis. In this study, we explore the reliability of manually transcribed data across different pathology fields in a prostate cancer database and also measure error rates attributable to the source data.

DESIGN

Descriptive study.

SETTING

Specialist urology service at a single centre in metropolitan Victoria in Australia.

PARTICIPANTS

Between 2004 and 2011, 1471 patients underwent radical prostatectomy at our institution. In a large proportion of these cases, clinicopathological variables were recorded by manual data-entry. In 2011, we obtained electronic versions of the same printed pathology reports for our cohort. The data were electronically imported in parallel to any existing manual entry record enabling direct comparison between them.

OUTCOME MEASURES

Error rates of manually entered data compared with electronically imported data across clinicopathological fields.

RESULTS

421 patients had at least 10 comparable pathology fields between the electronic import and manual records and were selected for study. 320 patients had concordant data between manually entered and electronically populated fields in a median of 12 pathology fields (range 10-13), indicating an outright accuracy in manually entered pathology data in 76% of patients. Across all fields, the error rate was 2.8%, while individual field error ranges from 0.5% to 6.4%. Fields in text formats were significantly more error-prone than those with direct measurements or involving numerical figures (p<0.001). 971 cases were available for review of error within the source data, with figures of 0.1-0.9%.

CONCLUSIONS

While the overall rate of error was low in manually entered data, individual pathology fields were variably prone to error. High-quality pathology data can be obtained for both prospective and retrospective parts of our data repository and the electronic checking of source pathology data for error is feasible.

Quality of care and analysis of surgical complications

BACKGROUND

During the past years evaluation of quality of care has become an important aspect of transparency of care, and complications is one of these parameters. Therefore, we analyzed the complication rate in an academic hospital over a 6-year period.

METHODS

During the period 2004-2009, all adult surgical patients admitted to and discharged from the Department of Surgery were selected for this time trend study. The Dutch national surgical complication registry was used in the analysis, which registers according to a three-tiered matrix-like classification system. Yearly changes in complication rates were analyzed statistically using the χ(2) for trend test. Subsequently, multivariable regression analysis was used to find significant independent predictors for sustaining a complication.

RESULTS

The mean complication rate per admission rose significantly from 0.18 in 2004 to 0.30 in 2009 (p < 0.001). The largest increase was observed by the following variables: less severe complications, complex surgical procedures, and ASA classification. Delirium, gastoparesis, and ileus were complications showing the largest increase. Age, male gender, ASA, and surgical complexity were found as independent predictors.

CONCLUSIONS

This study showed a significant increase of complications. The increase was mainly due to less severe complications, in particular delirium, ileus, and gastroparesis.

Variable impact of complications in general surgery: a prospective cohort study

BACKGROUND

Registering complications is important in surgery, since complications serve as outcome measures and indicators of quality of care. Few studies have addressed the variation in severity and consequences of complications. We hypothesized that complications show much variation in consequences and severity.

METHODS

We conducted a prospective observational cohort study to evaluate consequences and severity of complications in surgical practice. All recorded complications of patients admitted to our hospital between June 1, 2005, and Dec. 31, 2007, were prospectively recorded in an electronic database. Complications were classified according to the system of the Trauma Registry of the American College of Surgeons. We graded the severity of complications according to the system proposed by Clavien and colleagues, and the consequences of each complication were registered.

RESULTS

During the study period, 3418 complications were recorded; consequences and severity were recorded in 89% of them. Of 3026 complications, 987 (33%) were grade I, 781 (26%) were grade IIa, 1020 (34%) were grade IIb, 150 (5%) were grade III and 88 (3%) were grade IV. The consequences and severity of identically registered complications showed a large degree of variation, best illustrated by wound infections, which were grade I in 50%, grade IIa in 22%, grade IIb in 28% and grade III and IV in 0.3% of patients.

CONCLUSION

Severity should be routinely presented when reporting complications in clinical practice and surgical research papers to adequately compare quality of care and results of clinical trials.

Registration of surgical adverse outcomes: a reliability study in a university hospital

OBJECTIVE

Accurate registration of adverse surgical outcomes is essential to detect areas for improvement of surgical care quality. One reason for inaccurate adverse outcome registration may be the method to collect these outcomes. The authors compared the completeness of the national complication registry database (LHCR) as used in our hospital with relevant information from other available resources.

DESIGN

Retrospective reliability analysis.

SETTING

University hospital.

PARTICIPANTS

From the 3252 patients admitted to the surgical wards in 2010, the authors randomly selected a cohort of 180 cases, oversampling those with adverse outcomes. The LHCR contains adverse outcomes as reported during morning hand-offs or in discharge letters. The authors checked if the number and severity of adverse outcomes recorded in the LHCR agreed with those reported in morning hand-offs, discharge letters and medical and nursing files.

RESULTS

In 135 of 180 patients, all resources could be retrieved completely. Fourteen per cent of the patients with adverse outcomes were not recorded in the LHCR. Missing adverse outcomes were all reversible without the need for (re)operation, for example, postoperative pain, delirium or urinary tract complications. Only 38% of these adverse outcomes were reported in the morning hand-offs and discharge letters but were best reported in the medical and nursing files.

CONCLUSIONS

Registration of surgical adverse outcomes appears largely depending on the reliability of the underlying sources. For a more complete adverse outcome registration, the authors advocate a better hand-off and additional consultation of the patient's dossier. This extra effort allows for improvement actions to eventually avoid 'mild' adverse outcomes patients perceive as important and undesirable.

Increased consumption of hospital resources due to complications: an assessment of costs in a level I trauma center

BACKGROUND

Hospital complications can pose a threat to patients, contribute to higher mortality and morbidity, and increase both the average length of hospital stay (LOS) and the use of other resources. The purpose of this study is to express the relationship between complications and the use of hospital resources in financial parameters.

METHODS

All trauma patients admitted to the surgical ward in the period 2000 to 2008 were analyzed (n = 4,377). All activities registered during admission were obtained. The integral in-hospital cost prices of each activity were divided into various product groups. Median and interquartile ranges were presented for the number of activities in the product groups, stratified by age and Injury Severity Score. The relationship between both institutional- and trauma-related complications and the number of activities in the different product groups was tested with linear regression analysis with adjustment for confounding.

RESULTS

Significant associations between trauma-related complications and LOS, therapeutic paramedical products, diagnostic radiologic products, other diagnostic products, diagnostic laboratory products, therapeutic surgical procedures, other therapeutic products, and total costs (β = 5,420; 95% confidence interval, 4,912-5,929) were found. Significant associations between institutional-related complications and LOS, therapeutic paramedical products, diagnostic radiologic products, therapeutic surgical procedures, and other therapeutic products were found. Total costs (β = 170; 95% confidence interval, -760 to 1,099) showed a nonsignificant association with institutional-related complications.

CONCLUSION

Complications increase hospital costs, and even a small reduction in the number of complications will result in a substantial hospital cost savings and a reduction in the emotional and physical burdens of patients.

Prediction models for complications in trauma patients

BACKGROUND

Because the death rate among the total trauma population is low, other performance indicators in addition to the classical dependent variable mortality are required to assess the overall quality of trauma care. The aim of this study was to develop and validate a prediction model for the occurrence of complications that can be used to adjust a measure of quality of trauma care for case mix.

METHODS

Complications recorded in a trauma registry between 1997 and 2008 were analysed. Formulas for different types of complication (institution- or diagnosis-related) derived from logistic regression models were used to calculate the probability of absence of complications (PAC). Discriminative power was tested by calculating the area under the receiver operating characteristic curve (AUC) in test and validation samples. Calibration was tested using Hosmer and Lemeshow methodology.

RESULTS

Some 5944 surgical trauma admissions were included in the analysis. A significant association between both institution- and diagnosis-related complications and Injury Severity Score was found. Diagnosis-related complications were also associated with Glasgow Coma Score and age. The AUCs of the PACs for institution- and diagnosis-related complications were 0·64 and 0·75 respectively in the test sample, and 0·66 and 0·76 in the validation sample. The AUCs increased when the outcomes of the models were divided into subcategories of complications. Hosmer and Lemeshow tests were not significant for all models, except that for institutional complications.

CONCLUSION

To predict complications, a distinction should be made between institution- and diagnosis-related complications. The development of more detailed diagnosis-related prediction models is preferable because of better performance. The formulas predicting the PAC can be used to compare expected and observed complications.

The accuracy of complications documented in a prospective complication registry

BACKGROUND

The objectives of this study were to evaluate the accuracy of a prospective complication registry for documenting complications and identify possible factors for non-registering.

METHODS

Five hundred randomly selected patients admitted at the Department of Surgery of St. Elisabeth Hospital Tilburg, The Netherlands, in the year 2005, were evaluated for incidence and type of complications by an examination of their medical records and compared with a prospective complication registry. The system was independently reviewed by two persons for missing complications. Patient files with missing complications in the registry were screened for factors possibly responsible for non-registering.

RESULTS

Two hundred thirteen complications were detected, 58 (27%) missing in the registry. There were 50 different types of complications documented. The number of events missing per category were: drug-related (50%, n = 4), organ dysfunction (44%, n = 14), infection-related (25%, n = 19), surgery/intervention-related (23%, n = 14), and hospital-provider errors (19%, n = 7). Not all clinically important complications were adequately documented (e.g., anastomotic leakage). The kappa score was 0.695, making the interrater reliability substantial.

CONCLUSION

The accuracy of registering complications is fairly acceptable compared to the ranges mentioned in literature. It is disappointing that clinically important events are missing in the registry. The inaccuracy could be explained by a great diversity of documented events, due to a broad definition, suggesting ignorance of the responsible team of which events to register.

Incidence and type of complications in non-operated patients at a surgical ward

BACKGROUND

This study was designed to analyze a group of non-operated patients admitted to our surgical ward for incidence and type of documented complication. We classified and categorised these complications according to the definition of the Association of Surgeons of the Netherlands (ASN). Our main interest was to identify adverse events for non-operated patients that are caused by medical management and thus preventable.

METHODS

Complications were prospectively collected in our registry, which is part of an electronic medical patient file, and in retrospective analysed. All non-operated patients admitted to our surgical ward between January 2003 and January 2006 have been analysed for type and incidence of complications.

RESULTS

We recorded 437 complications in 364 (8%) of 4602 non-operated patients and we categorised 196 (45%) of these events in the Hospital - Provider group. In this last category 161 (82%) events were related to medical management and appeared to be preventable. Numerous different types of complications were recorded (n = 69) among the 437 events. Of all the complications, 75 (17%) were found to be a negative effect/failure of therapy.

CONCLUSION

The incidence of complications in non-operated patients at our surgical ward was 8%, with a great variety in types of events documented. Almost half of all complications (45%) were recorded in the Hospital-Provider category and appeared to be preventable, which needs further investigation.

Morbidity and mortality caused by cardiac adverse events after revascularization for critical limb ischemia

BACKGROUND

We assessed cardiac adverse events (AEs) after primary lower extremity arterial revascularization (LEAR) for critical lower limb ischemia (CLI) in order to evaluate the impact of cardiac AEs on the clinical outcome. We created an optimized care protocol concerning CLI patients' preoperative work-up as well as intra- and postoperative surveillance according to recent important literature and guidelines.

METHODS

We conducted a prospective analysis of clinical outcome after LEAR using patient-related risk factors, comorbidity, surgical therapy, and AEs. This cohort was divided into patients with and without AEs. AEs were categorized according to predefined standards: minor, surgical, failed revascularization, and systemic. The consequences of AEs were reoperation, additional medication, irreversible physical damage, and early death.

RESULTS

There were 106 patients (Fontaine III n=49, 46%, and Fontaine IV n=57, 56%) who underwent primary revascularization by bypass graft procedure (n=67, 63%) or balloon angioplasty (n=39, 37%). No difference in comorbidity was registered between the two groups. Eighty-four AEs were registered in 34 patients (32%). Patients experiencing AEs had significantly less antiplatelet agents (without AEs n=63, 88%, vs. with AEs n=18, 53%; p=0.000) and/or beta-blockers (without AEs n=66, 92%, vs. with AEs n=16, 47%; p=0.000) compared to patients without AEs. The two most harmful consequences of AEs were irreversible physical damage (n=3) and early death (n=8). Sixty percent (n=9) of systemic AEs were heart-related. The postprocedural mortality rate was 7.5%, with a 75% (n=6) heart-related cause of death.

CONCLUSION

AEs occur in >30% of CLI patients after LEAR. The most harmful AEs on the clinical outcome of CLI patients were heart-related, causing increased morbidity and death. Significant correlations between prescription of beta-blockers and antiplatelet agents and prevention of AEs were observed. A persistent focus on the prevention of systemic AEs in order to ameliorate the outcome after LEAR for limb salvage remains of utmost importance. Therefore, we advise the implementation of an optimized care protocol by discussing patients in a strict manner according to a predetermined protocol, to optimize and standardize the preoperative work-up as well as intra- and postoperative patient surveillance.

Anaesthesiological considerations in small-incision and laparoscopic cholecystectomy in symptomatic cholecystolithiasis: implications for pulmonary function. A randomized clinical trial

BACKGROUND

Upper abdominal surgery, including laparoscopic cholecystectomy (LC), is associated with post-operative pulmonary dysfunction. LC has, by consensus, become the treatment of choice for symptomatic cholecystolithiasis. Small-incision cholecystectomy (SIC), a procedure that does not require a pneumoperitoneum, threatens to be lost to clinical practice, even though there is evidence of equality. We hypothesized that the SIC technique should be equal, and might even be superior, to LC when considering post-operative pulmonary function because of the short incision length.

METHODS

A single-centre randomized clinical trial was performed including patients scheduled for elective cholecystectomy. Pulmonary flow-volume curves were measured pre-operatively, post-operatively and at follow-up. Blood gas analyses were measured pre-operatively, in the recovery phase and on post-operative day 1. Anaesthesia, analgesics and peri-operative care were standardized by protocol. Post-operatively, patients and caregivers were blind to the procedure.

RESULTS

Two hundred and fifty-seven patients were analysed. There was one pulmonary complication (pneumonia) in the LC group. In both groups, similar reductions of approximately 20% in pulmonary function parameters occurred, with complete recovery to pre-operative values. Patients in the SIC group consumed more analgesia when compared with the LC group, without any impact on blood gas analysis. Patients converted to a conventional open technique showed significant differences in six of the eight parameters in pulmonary function tests.

CONCLUSION

When evaluated with strict methodology and standardization of care, no clinically relevant differences were found between SIC and LC with regard to pulmonary function. Our results suggest that the popularity of the laparoscopic technique cannot be attributed to pulmonary preservation.

Adverse outcomes in surgical patients: implementation of a nationwide reporting system

PROBLEM

Lack of comparable data on adverse outcomes in hospitalised surgical patients.

DESIGN

A Plan-Do-Study-Act (PDSA) cycle to implement and evaluate nationwide uniform reporting of adverse outcomes in surgical patients. Evaluation was done within the Reach Efficacy-Adoption Implementation Maintenance (RE-AIM) framework.

SETTING

All 109 surgical departments in The Netherlands.

KEY MEASURES FOR IMPROVEMENT

Increase in the number of departments implementing the reporting system and exporting data to the national database.

STRATEGIES FOR CHANGE

The intervention included (1) a coordinator who could mediate in case of problems; (2) participation of an opinion leader; (3) a predefined plan of action communicated to all departments (including feedback of results during implementation); (4) connection with existing hospital databases; (5) provision of software and a helpdesk; and (6) an instrument based on nationwide standards.

EFFECTS OF CHANGE

Implementation increased from 18% to 34% in 1.5 years. The main reason for not implementing the system was that the Information Computer Technology (ICT) department did not link data with the hospital information system (lack of time, finances, low priority). Only 5% of the departments exported data to the national database. Export of data was hindered mainly by slow implementation of the reporting system (so that departments did not have data to export) and by concerns regarding data quality and public availability of data from individual hospitals.

LESSONS LEARNED

Hospitals need incentives to realise implementation. Important factors are financial support, sufficient manpower, adequate ICT linkage of data, and clarity with respect to public availability of data.

Design and implementation of an ICU incident registry

Due to its complexity intensive care is vulnerable to errors. On the ICU adults of the AMC (Amsterdam, The Netherlands) the available registries used for error reporting did not give insight in the occurrence of unwanted events, and did not lead to preventive measures. Therefore, a new registry has been developed on the basis of a literature study on the various terms and definitions that refer to unintended events, and on the methods to register and monitor them. As this registry intends to provide an overall insight into errors, a neutral term ('incident') -- which does not imply guilt or blame -- has been sought together with a broad definition. The attributes of an incident further describe the unwanted event, but they should not form an impediment for the ICU nurses and physicians to report. The properties of a registry that contribute to making it accessible and user friendly have been determined. This has resulted in an electronic registry where incidents can be reported rapidly, voluntarily, anonymously and free of legal consequences. Evaluation is required to see if the new registry indeed provides the ICU management with the intended information on the current situation on incidents. For further refinement of the design, additional development and adjustments are required. However, we expect that the awareness of errors of the ICU personnel has already improved, forming the first step to increased patient safety.

Categorisation of complications of endoscopic extraperitoneal and laparoscopic transperitoneal radical prostatectomy

The aim of the present review is to focus on the various attempts of categorisation of complications after endoscopic extraperitoneal and laparoscopic transperitoneal radical prostatectomy. Several classifications of complications and adverse events have been proposed in the literature but none is widely accepted or applied so far. We thus present a review of the existing literature and the complications of our series of 900 patients treated with endoscopic extraperitoneal radical prostatectomy (EERPE). We applied the recently revised Clavien classification system to grade EERPE complications.