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Vol. 102. Issue 8.
Pages 426-432 (August 2024)
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Vol. 102. Issue 8.
Pages 426-432 (August 2024)
Original article
Comparison and combination of three data sources from patient medical records to determine optimal quantification of postoperative morbidity according to the Clavien Dindo Classification and the Comprehensive Complication Index. A prospective study
Comparación y combinación de tres fuentes de datos de la historia clínica para determinar la cuantificación óptima de la morbilidad postoperatoria según la Clasificación de Clavien Dindo y el Comprehensive Complication Index. Estudio prospectivo
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Roberto de la Plaza Llamasa,b,
Corresponding author
dlplr@yahoo.es

Corresponding author.
, Paula Soto Garcíaa, Wenzhong Sunb, Ignacio Antonio Gemio del Reya,b, Daniel Alejandro Díaz Candelasb, Ludovica Gorinib, Farah Al Shwely Abduljabara,b, Raquel Aránzazu Latorre Fraguaa,b
a Departamento de Cirugía, Ciencias Médicas y Sociales, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Spain
b Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Guadalajara, Spain
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Tables (6)
Table 1. Description of the 200 surgical interventions classified in each group of the Operative Severity Score.
Table 2. Characteristics of the series.
Table 3. Classification of postoperative complications (PC) according to the Clavien Dindo Classification obtained from by the gold standard and different data sources.
Table 4. Number of postoperative complications (PC) per patient and Comprehensive Complication Index (CCI) registered according to the gold standard and each data source.
Table 5. Comparison of the degree of agreement of the 3 data sources with the gold standard according to the number of postoperative complications, Comprehensive Complication Index and degree of surgical complexity according to the Operative Severity Score.
Table 6. Assessment in the discharge report of the correct classification (in the global series and in patients presenting ≥1 postoperative complications) of the Clavien-Dindo Classification, the Comprehensive Complication Index, and both; comparison with the gold standard.
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Abstract
Introduction

It is currently unknown which data sources from the clinical history, or combination thereof, should be evaluated to achieve the most complete calculation of postoperative complications (PC).

The objectives of this study were: to analyze the morbidity and mortality of 200 consecutive patients undergoing major surgery, to determine which data sources or combination collect the maximum morbidity, and to determine the accuracy of the morbidity reflected in the discharge report.

Methods

Observational and prospective cohort study.

The sum of all PC found in the combined review of medical notes, nursing notes, and a specific form was considered the gold standard. PC were classified according to the Clavien Dindo Classification and the Comprehensive Complication Index (CCI).

Results

The percentage of patients who presented PC according to the gold standard, medical notes, nursing notes and form were: 43.5%, 37.5%, 35% and 18.7% respectively.

The combination of sources improved CCI agreement by 8%–40% in the overall series and 39.1–89.7 % in patients with PC. The correct recording of PC was inversely proportional to the complexity of the surgery, and the combination of sources increased the degree of agreement with the gold standard by 35 %–67.5% in operations of greater complexity.

The CDC and CCI of the discharge report coincided with the gold-standard values in patients with PC by 46.8% and 18.2%, respectively.

Conclusions

The combination of data sources, particularly medical and nursing notes, considerably increases the quantification of PC in general, most notably in complex interventions.

Keywords:
Morbidity
Postoperative complications
Postoperative period
Medical records
Nursing records
Data collection
Clavien Dindo classification
Comprehensive complication index
Resumen
Introducción

Actualmente se desconoce, qué fuentes de datos de la historia clínica o combinación de ellas se deben evaluar para conseguir el cómputo más completo de las complicaciones postoperatorias (CP).

Los objetivos de este estudio fueron: analizar la morbimortalidad de 200 pacientes consecutivos sometidos a cirugía mayor y definir qué fuentes de datos o combinación de ellas recogen la máxima morbilidad y, determinar la exactitud de la morbilidad reflejada en el informe de alta.

Métodos

Estudio de cohorte observacional y prospectivo.

Se consideró Gold-Standard la suma de todas las CP encontradas en la revisión combinada de evolutivos médicos, de enfermería y formulario específico. Las CP se clasificaron según la Clasificación de Clavien Dindo y el Comprehensive Complication Index (CCI)

Resultados

El porcentaje de pacientes que presentaron CP según el Gold-Standard, las notas médicas, de enfermería y formulario fueron: 43,5%, 37,5%, 35% y 18,7% respectivamente.

La combinación de fuentes mejoró la concordancia del CCI un 8–40% en la serie global y 39,1–89,7% en pacientes con CP. El registro correcto de CP es inversamente proporcional a la complejidad de la cirugía, y la combinación de fuentes aumenta un 35–67,5% el grado de concordancia con el Gold-Standard en operaciones de complejidad mayor.

La CDC y CCI del informe de alta coincidieron con los valores del Gold-Standard en los pacientes con CP un 46,8% y 18,2% respectivamente.

Conclusiones

La combinación de las fuentes de datos: notas médicas y enfermería aumenta considerablemente la cuantificación de CP en general y notablemente en las intervenciones complejas.

Palabras clave:
Morbilidad
Complicaciones postoperatorias
Periodo postoperatorio
Registros médicos
Registros de enfermería
Recolección de datos
Clasificación de Clavien Dindo
Comprehensive complication index

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