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.
Cir Esp (Engl Ed)
; 102(8): 426-432, 2024 Aug.
Article
en En
| MEDLINE
| ID: mdl-38705257
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.Palabras clave
Clasificación de Clavien Dindo; Clavien Dindo classification; Complicaciones postoperatorias; Comprehensive complication index; Data collection; Medical records; Morbidity; Morbilidad; Nursing records; Periodo postoperatorio; Postoperative complications; Postoperative period; Recolección de datos; Registros de enfermería; Registros médicos
Texto completo:
1
Colección:
01-internacional
Base de datos:
MEDLINE
Asunto principal:
Complicaciones Posoperatorias
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Registros Médicos
Límite:
Adult
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Aged
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Female
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Humans
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Male
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Middle aged
Idioma:
En
Revista:
Cir Esp (Engl Ed)
Año:
2024
Tipo del documento:
Article
Pais de publicación:
España