A. C. Antonacci1, S. Dechario1, J. Nicastro1, G. Coppa1, C. Antonacci2, M. Jarrett1 1North Shore University And Long Island Jewish Medical Center,Surgery,Manhasset, NY, USA 2Tulane University School Of Medicine,New Orleans, LA, USA
Introduction:
Collection and critique of actuarial complication data following surgery has been a historically difficult endeavor. Weekly Morbidity and Mortality conference (MMC) review combined with a standardized critique algorithm as part of a relational database can provide valuable cumulative data useful for evaluation of surgical quality.
Methods:
From January 2014 to July 2017, 62,377 general surgery operative procedures were performed at two major university based medical centers within our health system. We collected weekly Morbidity/Mortality reports from a total of 741 cases comprising 1714 adverse events (2.75% complication rate) and 194 deaths (0.31% mortality rate). Approximately 250 cases were presented in detail at MMC. However, all cases were analyzed for adverse event incidence, Clavien-Dindo risk profile, error assessment (i.e., diagnostic, judgment, technical, communication and system), management and high-risk surgery. Management evaluation was determined by a small group of senior surgeons not involved with individual cases. Reports were reviewed at the department and provider level, and used to guide quality improvement processes.
Results:
The overall mortality rate for the study group was 0.31%. Yet, the mortality rate for patients sustaining an adverse event was 25.9% (194/741), or 11.3% (194/1714) of adverse events. Patients without mortality sustained an average of 1.7 complications per case and patients who expired sustained an average of 2.84 complications per case. There were no statistically significant differences in the management of survivors vs. non-surviviors. Returns to the operating room (RTOR), death, intrabdominal abcess, return to interventional suite (RTIS), and hemorrhage requiring transfusion were the most common adverse events reported overall. Technical (60%), judgment (20.1%), system (13.1%) and diagnostic (6%) errors occurred with equal frequency between both campuses. Denominator adjusted complication and mortality rates in high-risk surgical procedures ranged from 6.5% to 23.5%, and as high as 2.8%, respectively. Over eighty-five percent (85%) of reported cases had Clavien Dindo scores between Grade IIIa and Grade V, confirming that post-operative RTIS, RTOR, ICU care for systemic disease and death were important features of the complication profile.
Conclusion:
Denominator adjusted morbidity and mortality rates are elevated well beyond reported overall rates. The number of complications following surgery are statistically associated with mortality, and patients who sustain a complication have an eleven percent (11%) risk of death. This methodology has implications not only for focused quality improvement, but for teaching a logical approach to self-assessment in the context of residency training. This project describes the feasibility of combining MMC with a standardized critique algorithm-based database to provide accurate risk-adjusted data useful for comprehensive assessment of surgical quality.