Comparación y combinación de tres fuentes de datos de la historia clínica para determinar la cuantificación óptima de la morbilidad posoperatoria según la Clasificación de Clavien Dindo y el Comprehensive Complication Index. Estudio prospectivo

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).

Objective

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.