Prediction of serious complications in patients admitted to a surgical ward

Creating an inexpensive hospital-wide surgical complication register for performance monitoring: a cohort study

Objectives

Basic tools that measure a hospital’s performance are required in order to benchmark or compare hospitals, but multispecialty institutional registries are rarely reported, and there is no consensus on their standard definitions and methodology. This study aimed to describe the setting up and first results of a hospital-wide surgical complication register that uses a minimal set of patient-related risk factors based on bedside data and produces outcomes data based on severity of complications.

Design

Cohort study.

Setting

Perioperative data related to all adult surgical procedures in a tertiary referral centre in Finland for 3 years (2016–2018) were included in the study. Complications were recorded according to a modified Clavien-Dindo classification, and the preoperative risk factors were compiled based on the literature and coded as numerical measures. The associations of preoperative risk factors with postoperative complications were analysed using the χ2 test or Fisher’s exact test.

Results

In total, 19 158 operations were performed between 2016 and 2018. Data on complications (Clavien 0–9) were recorded for 4529 surgical patients (23.6%), and 779 complications were reported (Clavien 1–9), leading to an overall complication rate of 17.2%. Of these, 4.6% were graded as major (Clavien 4–7). Patient-related risk factors with the strongest association with complications were growing American Society of Anesthesiologists Physical Status Classification System score (p<0.001), growing Charlson Index (p<0.001), poor nutritional status (Nutritional Risk Screening 2002), p=0.041) and urgency of surgery (p<0.001).

Conclusions

We describe an inexpensive hospital-wide surgical complication monitoring system that can produce valid numerical data for monitoring risk-adjusted surgical quality. The results showed that only a few patient-related risk factors were sufficient to account for the case mix.

Incidence of complications, organizational problems, and errors: Unexpected events in 1605 patients

PURPOSE

Besides surgical complications, a variety of adverse events may affect patients' comfort and outcome. The purpose of this prospective study was to identify the incidence and impact of all unexpected events in pediatric surgical patients.

METHODS

All unexpected events that occurred in our department during the period of February 2017-July 2018 were prospectively assessed. Complications associated with surgery, non-surgical treatment, errors and organizational problems were included. Events were classified using a modified version of Clavien-Dindo. Sentinel events were defined as death, serious injury, or the risk thereof (grade IV-V). Organizational events were analyzed separately. All events were discussed during morbidity and mortality-conferences, and the results and measures were documented.

RESULTS

Unexpected events occurred in 297 of 1605 patients (18.5%), of whom 1124 (70%) had undergone surgery. More than half of all events were not associated with an operation (n=237; 54%). The severity of all events was mostly minor (grade I-IIIb; n=410; 94%). Twenty-eight sentinel events (IV-V) occurred (6% of all events). Twenty-two (2%) patients died; however, none of these deaths were related to surgery. The top 5 events included organizational problems in 78 instants (18%), wound healing disorders in 44 (10%), recurrence of initial problems in 36 (8%), dislocation of indwelling catheters in 26 (6%) and bleeding in 16 (4%). Errors were identified in 15 patients (3%). We derived 10 changes of concepts of management or treatment.

CONCLUSION

The incidence of unexpected events in pediatric surgical patients is high when complications associated with surgical and non-surgical treatment and organizational alterations are documented prospectively. In our study, most events were minor and did not substantially affect patients' outcomes. Prospective assessment helped to identify organizational shortcomings and develop preventive strategies.

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.

Experiences with the standardized classification of surgical complications (Clavien-Dindo) in general surgery patients

Background

The standardized Clavien-Dindo classification of surgical complications is applied as a simple and widely used tool to assess and report postoperative complications in general surgery. However, most documentation uses this classification to report surgery-related morbidity and mortality in a single field of surgery or even particular intervention. The aim of the present study was to present experiences with the Clavien-Dindo classification when applied to all patients on the general surgery ward of a tertiary referral care center.

Methods

We analyzed a period of 6 months of care on a ward with a broad range of general and visceral surgery. Discharge reports and patient charts were analyzed retrospectively and reported complications rated according to the most recent Clavien-Dindo classification version. The complexity of operations was assessed with the Austrian Chamber of Physicians accounting system.

Results

The study included 517 patients with 817 admissions, of whom 463 had been operated upon. Complications emerged in 12.5%, of which 19% were rated as Clavien I, 20.7% as Clavien II, 13.8% as Clavien IIIa, 27.6% as Clavien IIIb, 8.6% as Clavien IVa, and 10.3% as Clavien V. No Clavien grade IVb complication occurred within the investigation. Patients having undergone more complex surgery or with higher scores experienced significantly longer lengths of hospital stay.

Conclusion

The Clavien-Dindo classification can easily be used to document complication rates in general surgery, even though this collective was not included in the original validation studies of Clavien et al. and consisted of more heavily impaired patients.

Simulation of patient flow in multiple healthcare units using process and data mining techniques for model identification

INTRODUCTION

An approach to building a hybrid simulation of patient flow is introduced with a combination of data-driven methods for automation of model identification. The approach is described with a conceptual framework and basic methods for combination of different techniques. The implementation of the proposed approach for simulation of the acute coronary syndrome (ACS) was developed and used in an experimental study.

METHODS

A combination of data, text, process mining techniques, and machine learning approaches for the analysis of electronic health records (EHRs) with discrete-event simulation (DES) and queueing theory for the simulation of patient flow was proposed. The performed analysis of EHRs for ACS patients enabled identification of several classes of clinical pathways (CPs) which were used to implement a more realistic simulation of the patient flow. The developed solution was implemented using Python libraries (SimPy, SciPy, and others).

RESULTS

The proposed approach enables more a realistic and detailed simulation of the patient flow within a group of related departments. An experimental study shows an improved simulation of patient length of stay for ACS patient flow obtained from EHRs in Almazov National Medical Research Centre in Saint Petersburg, Russia.

CONCLUSION

The proposed approach, methods, and solutions provide a conceptual, methodological, and programming framework for the implementation of a simulation of complex and diverse scenarios within a flow of patients for different purposes: decision making, training, management optimization, and others.

Prospective assessment of complications on a daily basis is essential to determine morbidity and mortality in routine pediatric surgery

AIMS OF THE STUDY

We aimed to assess postoperative complications prospectively on a daily basis and hypothesized that this would lead to an increase in the number of detected complications.

METHODS

Surgical complications were assessed prospectively during a period of 8months. Systematic documentation was carried out daily during a team meeting (period S). Data were compared to those of a preceding period of 8-months of nonsystematic assessment (period N) in which complications had been documented in a self-reporting fashion. Complications were classified according to the Clavien-Dindo classification.

RESULTS

A total of 1291 patients (mean age: 6.6years) were included. During period S complications were determined in 16% of 790 operations compared to 4% of 741 procedures in period N (p<0.01). This difference was owing to an increased detection of minor complications (grade I-III), i.e. wound infection, dysuria after hypospadias repair or postoperative bleeding. In contrast, the incidence of severe complications (grade IV+V) was not significantly different between the time periods (1.3% in period S and 0.8% in period N). Most frequent major complications were cardiopulmonary arrest, enterocolitis, and death. Severe complications accounted for 8% of complications discussed during weekly morbidity and mortality conferences in period S versus 22% in period N (p<0.05).

CONCLUSION

Our results indicate that a systematic documentation of complications on a daily basis reveals a more realistic picture of the incidence of pediatric surgical complications and should be the method of choice.

Hospital costs of complications after a pancreatoduodenectomy

BACKGROUND

A pancreatoduodenectomy (PD) is a highly advanced procedure associated with considerable post-operative complications and substantial costs. In this study the hospital costs associated with complications after PD were assessed.

METHODS

A retrospective cohort study was conducted on 100 consecutive patients who underwent a pylorus-preserving (PP)PD between January 2012 and July 2013. Per patient, all complications occurring during admission or in the 30-day period after discharge were documented. All hospital costs related to the (PP)PD were defined as the costs of all medical interventions and resources during the hospitalisation period as recorded by the electronic supply tracking system.

RESULTS

The median hospital costs ranged from €17 482 for a patient without complications to €55 623 for a patient with a post-operative haemorrhage. A post-operative haemorrhage was associated with a 39.6% increase in total hospital costs after adjusting for patient characteristics. Other factors significantly associated with an increase in total hospital costs were: the presence of a malignancy other than a pancreatic adenocarcinoma (29.4% cost increase), the severity grade of a complication (34.3-70.6% increase) and the presence of a post-operative infection (32.4% increase).

CONCLUSIONS

This study provides an in-depth analysis of hospital costs and identifies factors that are associated with substantial cost consequences of specific complications occurring after a PD.

Post-surgical complication prediction in the presence of low-rank missing data

The problem of missing data has made it difficult to analyze Electronic Health Records (EHR). In EHR data, the "missingness" often results from the low-rank property: each patient is considered a mixture of prototypical patients, and certain types of patients will have similar missing entries in their records. However, most existing methods to deal with missing data fail to capture this low-rank property of missing data. Hence we propose to use matrix factorization and matrix completion methods to perform prediction in the presence of missing data. We validated our methods in the task of post-surgical complication prediction and experimental results show that our method can improve the prediction accuracy significantly.

Prognostic factors for morbidity and mortality in elderly patients undergoing acute gastrointestinal surgery: a systematic review

BACKGROUND

Elderly patients undergoing acute gastrointestinal (GI) surgery experience increased morbidity and mortality compared with younger and elective patients. Prognostic factors can be used to counsel patients of these risks and, if modifiable, to minimize them. We reviewed the literature on prognostic factors for adverse outcomes in elderly patients undergoing acute GI surgery.

METHODS

We searched PubMed and Embase using a strategy developed in collaboration with an expert librarian. Studies examining independent associations between prognostic factors and morbidity or mortality in patients aged 65 and older undergoing acute GI surgery were selected. We extracted data using a standardized form and assessed study quality using the QUIPS tool.

RESULTS

Nine cohort studies representing 2958 patients satisfied our selection criteria. All studies focused on postoperative mortality. Thirty-four prognostic factors were examined, with significant variability across studies. There was limited or conflicting evidence for most prognostic factors. Meta-analysis was only possible for the American Society of Anesthesiologists (ASA) score, which was found to be associated with mortality in 4 studies (pooled odds ratio 2.77, 95% confidence interval 0.92-8.41).

CONCLUSION

While acute GI surgery in elderly patients is becoming increasingly common, the literature on prognostic factors for morbidity and mortality in this patient population lags behind. Further research is needed to help guide patient care and potentially improve outcomes.

Predictors of septic shock following anastomotic leak after major gastrointestinal surgery: An audit from a tertiary care institute

Background:

Anastomotic leak is a serious complication after major gastrointestinal surgery and majority of deaths occur due to septic shock. Therefore, the early identification of risk factors of septic shock may help reduce the adverse outcomes.

Objective:

The aim of this audit was to determine the predictors of septic shock in patients with anastomotic leak after major gastrointestinal surgery.

Design:

Retrospective, audit.

Materials and Methods:

The patients admitted in the gastrosurgical intensive care unit ICU) of our institute between September 2009 and April 2012 with anastomotic leakage after surgery were identified. The ICU charts were retrieved from the database to identify the patients progressing to septic shock. A comparison of risk factors was made between the patients who developed septic shock (septic shock group) against the patients who did not (non-septic shock group).

Results:

The study sample comprised of 103 patients with anastomotic leak, of which 72 patients developed septic shock. The septic shock group had a higher APACHE II score, lower MAP, and higher HR at the time of ICU admission. They received greater transfusion of packed red blood cells during their ICU stay. Septic shock was more common after pancreaticojejunostomy and hepaticojejunostomy leaks.

Conclusion:

Presence of malignancy, chronic obstructive pulmonary disease (COPD), packed red blood cell transfusion, bacteremia, and hepaticojejunostomy or pancreaticojejunostomy leaks were independent predictors of mortality and length of ICU stay. To the best of our knowledge there are no available studies in the literature on the predictors of risk factors of septic shock in patients with anastomotic leakage.

Risk of morbidity, mortality, and recurrence after parastomal hernia repair: a nationwide study

BACKGROUND

Surgical outcome results after repair for parastomal hernia are sparsely reported and based on small-scale studies.

OBJECTIVE

This study aims to analyze surgical risk factors for 30-day reoperation and mortality, and, secondarily, to report the risk of reoperation for recurrence.

DESIGN

This is a retrospective analysis of nationwide perioperative surgical variables. The primary outcome was reoperation for surgical complications and/or mortality within 30 days after parastomal hernia repair. Follow-up was obtained from the Danish National Patient Register. Detailed patient-related data were based on hospital files. Multivariate analysis was based on a compound parameter: 30-day reoperation or death.

SETTING AND PATIENTS

All patients with a parastomal hernia repair registered in the Danish Hernia Database from January 1, 2007 to December 31, 2010 were included.

MAIN OUTCOME MEASURES

Univariate and logistic regression was used to identify risk factors for 30-day reoperation or death.

RESULTS

The study included 174 patients with a parastomal hernia repair (142 elective and 32 emergency repairs; 56 open and 118 laparoscopic repairs). Median follow-up was 20 months (range, 0-47). A total of 13.2% were reoperated because of postoperative complications, and 6.3% of patients died within the first 30 postoperative days. Emergency repair was the strongest risk factor for reoperation or death in multivariate analyses (OR, 7.6; 95% CI, 2.7-21.5). No difference was found in preoperative risk of poor outcome between elective and emergency repairs (Charlson score 4 (range, 0-12) vs 5 (0-11), p = 0.07). After 3 years, the cumulated reoperation rate for recurrence was 10.8% (open 17.2% and laparoscopic 3.8%).

LIMITATIONS

Patients' comorbidity was based on retrospective data, and the study had a relatively short follow-up.

CONCLUSION

In the present nationwide study, repair for a parastomal hernia was associated with high rates of morbidity, mortality, and repair for recurrence. Emergency repair was the only important risk factor to predict poor 30-day postoperative outcome.

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.

An evaluation of the Charlson co-morbidity score for predicting sepsis after elective major surgery

BACKGROUND AND AIMS

Severe sepsis is a significant cause of morbidity and mortality following major surgery. The Charlson co-morbidity score (CCS) has been shown to be associated with severe sepsis following major surgery for cancer. This prospective observational study investigated the effect of patient factors (CCS, gender, age and malignancy) and intraoperative factors (duration of surgery and allogeneic blood transfusion) on the incidence of sepsis after elective major surgery, and the impact of patient co-morbidities on length of stay in critical care.

MATERIALS AND METHODS

We prospectively identified a cohort of 101 patients undergoing elective major surgery in a university teaching hospital. The CCS was calculated before surgery, and the incidence of sepsis was documented following surgery. We investigated whether age, malignancy, intraoperative allogeneic blood transfusion, length of surgery or gender were associated with sepsis following surgery.

RESULTS

Twenty-seven (27%) patients developed sepsis. Using multivariate logistic regression, the duration of surgery was associated with the development of sepsis after surgery (P = 0.054, odds ratio 1.2). The CCS was not associated with sepsis in this population of cancer and non-cancer patients undergoing elective major surgery, but was associated with longer length of stay in the intensive care unit (P = 0.016).

CONCLUSIONS

Duration of surgery, but not patient co-morbidity as assessed by the CCS, may predict the postoperative incidence of sepsis. CCS could be used as a guide to predict consumption of critical care resources by elective surgical patients. A higher CCS was associated with a longer ICU stay. Resources, such as postoperative goal directed therapy, may be useful in reducing length of stay, hospital costs and risks of infective complications in this subgroup of patients with higher CCS.

Pre-operative risk scores for the prediction of outcome in elderly people who require emergency surgery

Background

The decision on whether to operate on a sick elderly person with an intra-abdominal emergency is one of the most difficult in general surgery. A predictive risk-score would be of great value in this situation.

Methods

A Medline search was performed to identify those predictive risk-scores relevant to sick elderly patients in whom emergency surgery might be life-saving.

Results

Many of the risk scores for surgical patients include the operative findings or require tests which are not available in the acute situation. Most of the relevant studies include younger patients and elective surgery. The Glasgow Aneurysm Score and Hardman Index are specific to ruptured aortic aneurysm while the Boey Score and the Hacetteppe Score are specific to perforated peptic ulcer. The Reiss Index and Fitness Score can be used pre-operatively if the elements of the score can be completed in time. The ASA score, which includes a significant element of subjective clinical judgement, can be augmented with factors such as age and urgency of surgery but no test has a negative predictive value sufficient to recommend against surgical intervention without clinical input.

Conclusion

Risk scores may be helpful in sick elderly patients needing emergency abdominal surgery but an experienced clinical opinion is still essential.

Bioelectric impedance and individual characteristics as prognostic factors for post-operative complications

BACKGROUND AND AIMS

Malnutrition increases morbidity and mortality in surgical patients, and for this reason, several nutritional markers have been used as prognostic tools to identify surgical patients under a higher risk to develop complications in post-operative period. Few studies show the impact of nutritional markers after controlling for others variables, such as age and severity of disease. A new method, bioelectric impedance analysis (BIA), and its parameter, phase angle, have been described as a prognostic tool in several clinical situations, but they have never been studied in surgical population. The objective of this work is to assess the importance of nutritional variables and parameters from BIA as predictors of post-operative complications in a multivariable regression model.

METHODS

The nutritional status of 225 adult patients scheduled to undergo gastrointestinal surgery was assessed by several methods, including bioelectric impedance analysis and subjective global assessment. Potential confounding factors were also studied. Patients were screened for post-operative complications until hospital discharge.

RESULTS

Weight loss greater than 10%, subjective global assessment, nutritional risk assessment, ECM/BCM ratio and phase angle (from BIA) were the prognostic factors significantly associated with post-operative complications in the crude analysis. After adjusting for sex, age, marital status, tumors and pre-operative infections, only phase angle remained as a prognostic factor (RR=4.3; CI95% 1.6-11.8 for phase angle <-0.8 sd), while the other nutritional variables lost their association with post-operative complications.

CONCLUSION

Phase angle remains as an important prognostic factor for postoperative complications, even after adjusting for other individual predictors and confounders. Its utility in the identification of patients eligible for nutritional therapy has now to be evaluated.

A scoring system identified near-miss maternal morbidity during pregnancy

OBJECTIVE

The objective of this study was to develop a scoring system for identifying women with near-miss maternal morbidity, and differentiating these women from those with severe but not life-threatening conditions.

STUDY DESIGN AND SETTING

The study was conducted at the University of Illinois Medical Center at Chicago (UIMC), which is a tertiary care hospital with approximately 2,220 births per year. UIMC is in a major urban area serving a predominantly African-American and Latina population. This article focuses on five clinical factors: organ failure (>/=1 system), extended intubation (>12 hr), ICU admission, surgical intervention, and transfusion (>3 units), grouped into several scoring system alternatives. The total score on each scoring system was calculated as the weighted sum of the clinical factors present for each woman.

RESULTS

The five-factor scoring system had the highest specificity (93.9%), but the four-factor scoring system, which eliminated organ system failure for simplification of data collection, still had a specificity of 78.1%.

CONCLUSION

Near-miss morbidities identified using the scoring systems presented can be incorporated into clinical case review and epidemiologic studies to enhance the monitoring of obstetric care and to improve estimates of the incidence of life-threatening complications in pregnancy.

[Relation between activity volume and surgeon's results: myth or reality?]

The relationship between volume and surgical outcome seems logical, but needs to be demonstrated in the real world. A qualitative systematic review has been conducted to verify this hypothesis. Five systematic reviews and hundred original papers have been retrieved and analysed. Most of the studies were retrospective and used administrative data instead of medical charts. Moreover few studies involved a good case mix adjustment when comparing surgical units or individual surgeons. These methodological flaws do not allow any evidence based conclusions. Even though a positive relationship is suggested for surgical units, the relationship between volume and outcome was however less obvious for an individual surgeon. There is some evidence that the relationship varied greatly according to the specialty or the procedure evaluated. A new approach based on predictive scores comparing expected versus observed outcomes is mandatory and seems to be the best way to assess objectively the relationship between surgical volume and outcomes.