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Surgical Closure of Equine Abdomen, Prevention, and Management of Incisional Complications
Published on: May 10, 2024
A Survey of Surgeons' Perceptions of Defining and Recording Complications Associated With Elective, Emergency and
Chen Lew1,2, Kalai Shaw1, Anagi Wickramesinghe3
1Department of General Surgery, The Alfred Hospital, Melbourne, Victoria, Australia.
Insights
Surgeons show varied interpretations of surgical complications, especially in emergency general surgery (EGS). Current classification systems need refinement to accurately capture adverse events in acute care settings and improve patient outcomes.
Area of Science:
- Surgical outcomes research
- Patient safety and quality improvement
Background:
- The Clavien-Dindo (CD) classification, developed for elective surgery, defines complications narrowly within the post-operative course.
- Its application to emergency general surgery (EGS) is limited, potentially under-capturing adverse events relevant to overall surgical care quality due to pre/non-operative factors.
Purpose of the Study:
- To explore how general surgeons interpret and define surgical complications in both elective and EGS settings.
- To identify limitations in current complication classification frameworks within acute surgical care.
Main Methods:
- A cross-sectional survey was conducted with 76 general surgeons across four public hospitals in Melbourne.
- Participants reviewed 43 clinical vignettes covering pre-operative, intra-operative, post-operative, post-discharge, and non-operative care, classifying events as complications under the CD system.
Main Results:
- A 72% response rate was achieved, with 93% of respondents having EGS experience.
- Surgeon acceptance of events as complications varied widely (15% to 100%), with fair concordance (Fleiss' Kappa = 0.254).
- Events in pre-operative/non-operative phases were broadly accepted as complications, but minor events or those not requiring intervention were often disregarded; perceived accountability influenced recognition.
Conclusions:
- Significant variability exists in classifying surgical complications in EGS, indicating limitations of current frameworks in acute contexts.
- Refining classification systems to incorporate surgeon perspectives is crucial for improving audit accuracy and capturing EGS complexity.
- Enhanced classification can ultimately lead to better patient care in emergency surgical settings.
Background:
The Clavien-Dindo (CD) classification, derived in elective surgery, limits complications to deviations from the post-operative course. The interpretation of this definition has not been examined. The application of the CD definition to emergency general surgery (EGS) is limited as many EGS patients have a pre/non-operative component of care allowing under-capture of adverse events that are relevant to quality of surgical care. This study aimed to explore how surgeons interpret and define complications across elective and EGS settings.
Methods:
We conducted a cross-sectional survey of 76 general surgeons across four Melbourne public hospitals. With reference to 43 clinical vignettes spanning pre-operative, intra-operative, post-operative, post-discharge, and non-operative care domains respondents indicated whether events constituted complications under the CD classification.
Results:
The response rate was 72% and 93% of respondents reported EGS experience. Acceptance of individual events ranged from 15% (post-operative fever) to 100% (intra-operative neuropraxia). There was broad acceptance that events occurring during pre-operative and non-operative care could be classified as complications. Minor physiological changes and events not requiring intervention were often disregarded as complications. Perceived accountability influenced responses, with complications more likely to be recognized when linked directly with surgical care. Agreement on classification was only fair (Fleiss' Kappa = 0.254), indicating only fair concordance in complication classification.
Conclusions:
This study demonstrates significant variability in the classification of surgical complications within EGS, highlighting the limitations of current frameworks particularly in the acute contexts. Incorporating surgeon perspectives into refined classification systems may improve audit accuracy, better capture the complexity of EGS, and ultimately enhance patient care.
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