Assessment of postoperative morbidity in Spanish hospitals: Results from a national survey.

BACKGROUND: The methodology used for recording, evaluating and reporting postoperative complications (PC) is unknown. The aim of the present study was to determine how PC are recorded, evaluated, and reported in General and Digestive Surgery Services (GDSS) in Spain, and to assess their stance on morbidity audits. METHODS: Using a cross-sectional study design, an anonymous survey of 50 questions was sent to all the heads of GDSS at hospitals in Spain. RESULTS: The survey was answered by 67 out of 222 services (30.2%). These services have a reference population (RP) of 15 715 174 inhabitants, representing 33% of the Spanish population. Only 15 services reported being requested to supply data on morbidity by their hospital administrators. Eighteen GDSS, with a RP of 3 241 000 (20.6%) did not record PC. Among these, 7 were accredited for some area of training. Thirty-six GDSS (RP 8 753 174 (55.7%) did not provide details on all PC in patients' discharge reports. Twenty-four (37%) of the 65 GDSS that had started using a new surgical procedure/technique had not recorded PC in any way. Sixty-five GDSS were not concerned by the prospect of their results being audited, and 65 thought that a more comprehensive knowledge of PC would help them improve their results. Out of the 37 GDSS that reported publishing their results, 27 had consulted only one source of information: medical progress records in 11 cases, and discharge reports in 9. CONCLUSIONS: This study reflects serious deficiencies in the recording, evaluation and reporting of PC by GDSS in Spain.

Surgical Infection Reduction Program of the Observatory of Surgical Infection (PRIQ-O): Delphi prioritization and consensus document on recommendations for the prevention of surgical site infection.

Surgical site infection is the most frequent and avoidable complication of surgery, but clinical guidelines for its prevention are insufficiently followed. We present the results of a Delphi consensus carried out by a panel of experts from 17 Scientific Societies with a critical review of the scientific evidence and international guidelines, to select the measures with the highest degree of evidence and facilitate their implementation. Forty measures were reviewed and 53 recommendations were issued. Ten main measures were prioritized for inclusion in prevention bundles: preoperative shower; correct surgical hand hygiene; no hair removal from the surgical field or removal with electric razors; adequate systemic antibiotic prophylaxis; use of minimally invasive approaches; skin decontamination with alcoholic solutions; maintenance of normothermia; plastic wound protectors-retractors; intraoperative glove change; and change of surgical and auxiliary material before wound closure.

Validation of prolonged length of stay as a reliable measure of failure to rescue in colorectal surgery.

BACKGROUND: Failure-to-rescue measures a hospital's response capacity to avoid the death of a patient after a complication. The aim of this study was to validate the use of prolonged length of stay to calculate failure-to-rescue rates as a substitute for traditional coding of complications in colorectal cancer surgery. METHOD: We performed a cross-sectional between-instruments agreement study. Our study population was comprised of 204 colorectal cancer surgical patients from a public academic hospital during 2017 and 2018. We obtained two failure-to-rescue indicators from administrative data: an indicator using International Classification of Diseases, tenth edition, (ICD-10) codes; and another one using a cut-off point of prolonged length of stay as a predictor of patients with complications. Then, they were compared with a reference indicator from clinical records. RESULTS: Failure-to-rescue rates were between 10 and 13.64 for the study site depending on which indicator was used. A hospital stay ≥10 days had the maximum Youden's index (0.6) and an area under the ROC curve of 0.87. This was used in the failure-to-rescue indicator using prolonged length, which obtained the highest agreement (any coefficient >0.75). CONCLUSION: ICD-10 codes identified complications poorly. Prolonged length of stay could be a valid replacement of ICD-10 codes when measuring failure-to-rescue in administrative databases for colorectal surgical patients.

Patient satisfaction, an indicator to consider in the colorectal cancer process.

Colorectal cancer (CRC) is one of the most relevant diseases worldwide because of its incidence, prevalence and mortalitye. It is the third most common tumor in men, after lung and prostate cancer, and the second most common tumor in women, after breast cancer. A recent systematic analysis showed global data referring to age-standardized incidence rates for CRC, which increased by 9.5% from 1990 to 2017, whereas mortality rates decreased by 13.5%. This might be due to the introduction of CRC prevention programs, which facilitate early identification and higher survival chances.

Is cholecystectomy the treatment of choice for acute acalculous cholecystitis? A systematic review of the literature.

BACKGROUND AND OBJECTIVES: There is currently no consensus with regard to the use of cholecystectomy or percutaneous cholecystostomy as the therapy of choice for acute acalculous cholecystitis. The goal of this study was to review the scientific evidence on the management of these patients according to clinical and radiographic findings. METHODS: A systematic review of the literature from 2000 to 2016 was performed. The databases of PubMed, Índice Médico Español, Cochrane Library and Embase were searched according to the following inclusion criteria: publication language (English or Spanish), adult patients, acalculous etiology and appropriate study design. RESULTS: A total of 1,013 articles were identified and ten articles were selected for review. These included five observational controlled studies and five case series which described the outcome of patients treated with percutaneous cholecystostomy and emergency cholecystectomy. No prospective or randomized studies were identified using the search criteria. The data from the literature and analysis of results suggested that percutaneous cholecystostomy may be a definitive therapy for acute acalculous cholecystitis with no need for subsequent elective cholecystectomy. CONCLUSIONS: Percutaneous cholecystostomy may be the first treatment option for patients with acute acalculous cholecystitis except in cases with a perforation or gallbladder gangrene. Patients at low surgical risk may benefit from cholecystectomy but both treatment options may be effective. Percutaneous cholecystostomy in patients with acute acalculous cholecystitis may be a definitive therapy with no need for a subsequent elective cholecystectomy. However, the overall quality of studies is low and the final recommendations should be considered with caution.

Development and pilot study of an essential set of indicators for general surgery services. / Desarrollo y estudio piloto de un conjunto esencial de indicadores para los servicios de cirugía general.

INTRODUCTION: At present there is a lack of appropriate quality measures for benchmarking in general surgery units of Spanish National Health System. The aim of this study is to present the selection, development and pilot-testing of an initial set of surgical quality indicators for this purpose. METHODS: A modified Delphi was performed with experts from the Spanish Surgeons Association in order to prioritize previously selected indicators. Then, a pilot study was carried out in a public hospital encompassing qualitative analysis of feasibility for prioritized indicators and an additional qualitative and quantitative three-rater reliability assessment for medical record-based indicators. Observed inter-rater agreement, prevalence adjusted and bias adjusted kappa and non-adjusted kappa were performed, using a systematic random sample (n=30) for each of these indicators. RESULTS: Twelve out of 13 proposed indicators were feasible: 5 medical record-based indicators and 7 indicators based on administrative databases. From medical record-based indicators, 3 were reliable (observed agreement >95%, adjusted kappa index >0.6 or non-adjusted kappa index >0.6 for composites and its components) and 2 needed further refinement. CONCLUSIONS: Currently, medical record-based indicators could be used for comparison purposes, whilst further research must be done for validation and risk-adjustment of outcome indicators from administrative databases. Compliance results in the adequacy of informed consent, diagnosis-to-treatment delay in colorectal cancer, and antibiotic prophylaxis show room for improvement in the pilot-tested hospital.

Recommendations of «not-to-do¼: Proposals of the Spanish Association of Surgeons to the project «Commitment to quality of scientific societies¼. / Recomendaciones de «no hacer¼: propuestas de la Asociación Española de Cirujanos al proyecto de «Compromiso por la calidad de las sociedades científicas¼.

INTRODUCTION: The initiative of the Spanish Ministry of Health «Commitment to quality of scientific societies¼, aims to reduce unnecessary interventions of healthcare professionals. METHODS: The Spanish Association of Surgeons has selected 22 experts from the different sections that have participated in the identification of 26 proposals «do not do¼ to be ordered by the expected impact its implementation would have according to the GRADE methodology. From these proposals, the Delphi technique was used to select 5 recommendations presented in more detail in this article. RESULTS: The 5 selected recommendations are: Do not perform cholecystectomy in patients with asymptomatic cholelithiasis; do not keep bladder catheterization more than 48hours; do not extend antibiotic prophylaxis treatments more than 24hours after a surgical procedure; do not perform routine antibiotic prophylaxis for uncomplicated clean and no prosthetic surgery; and do not use antibiotics postoperatively after uncomplicated appendicitis. CONCLUSION: The Spanish Association of Surgeons's participation in this campaign has allowed a reflection on those activities that do not add value in the field of surgery and it is expected that the spread of this process serves to reduce its performance.

Clinical Pathway for Thyroidectomy.

Clinical pathways are care plans applicable to patient care procedures that present variations in practice and a predictable clinical course. They are designed not as a substitute for clinical judgment, but rather as a means to improve the effectiveness and efficiency of the procedures. This clinical pathway is the result of a collaborative work of the Sections of Endocrine Surgery and Quality Management of the Spanish Association of Surgeons. It attempts to provide a framework for standardizing the performance of thyroidectomy, the most frequently performed operation in endocrine surgery. Along with the usual documents of clinical pathways (temporary matrix, variance tracking and information sheets, assessment indicators and a satisfaction questionnaire) it includes a review of the scientific evidence around different aspects of pre, intra and postoperative management. Among others, antibiotic and antithrombotic prophylaxis, preoperative preparation in hyperthyroidism, intraoperative neuromonitoring and systems for obtaining hemostasis are included, along with management of postoperative hypocalcemia.

Implantación de un programa de tratamiento integral de la pared abdominal: hernia incisional y abdominoplastia Resultados preliminares / Implementation of a program of integral treatment of the abdominal wall: incisional hernia and abdominoplasty. Preliminary results

Introducción. Las vías clínicas son planes asistenciales sistematizados para determinados procesos hospitalarios, que constituyen una herramienta que coordina a múltiples profesionales implicados en un objetivo común. La abdominoplastia es una de las operaciones que con mayor frecuencia practican el cirujano plástico y el cirujano general, pero no existe ningún consenso sobre cómo debe hacerse cuando existe una hernia incisional o quirúrgica asociada. En el presente trabajo se presenta el proceso de elaboración de la vía clínica del proceso "hernia incisional y abdominoplastia". Metodología. La elaboración de la vía clínica se ha llevado a cabo mediante reuniones semanales durante tres meses. El grupo implicado ha estado formado por cirujanos, anestesiólogos, enfermeros y coordinadores de calidad de cirugía y enfermería. Se hizo un análisis de una serie previa y, además, una revisión bibliográfica con gradación de la evidencia científica, tanto del proceso "hernia incisional", como de otras vías clínicas publicadas. Con ello, se elaboraron los documentos principales de la vía clínica, los cuales se discutieron con los miembros del servicio de cirugía y las unidades de enfermería. Resultados. Se presentan todos los documentos y protocolos de asistencia previos y posteriores a la hospitalización de los pacientes con eventración. Conclusión. La eventración puede ser sistematizada en una vía clínica que pretende estandarizar los cuidados y mejorar los resultados futuros.

Introduction: Clinical pathways are standard care plans for certain processes. They are specially useful in those procedures that are frequent and with nonjustified variability. In addition it is advisable to initiate the way of the clinical pathways with processes that have a predictable clinical course. Clinical pathways constitute a tool that coordinates all the implied professionals, so the joint work of doctors and nurses is fundamental. Abdominoplasty is one of the operations most commonly performed by plastic surgeon and the general surgeon, but there is no consensus about how it should be done if there is a ventral hernia associated. The objective of this work is to present the elaboration and evaluation of the clinical pathway of the incisional hernioplasty. Methodology: The elaboration of the clinical pathway has been carried out by means of weekly meetings of all the group during 3 months. The group was made by surgeons, anaesthetists, nurses of the different implied units and the quality coordinators of surgery and nursery. A bibliographical search with scientific evidence as well as of other published clinical routes has been performed. Then the main documents of the clinical pathway were elaborated and discussed with the members of the service of surgery and units of nursery. Results: The protocols of attendance in the pre- and postoperative period, as well as the main documents of the clinical pathway are presented. Conclusion: The incisional hernia repair is a suitable process to initiate the systematization of the clinical pathways.

National survey on patient's fears before a general surgery procedure.

OBJECTIVE: To assess the magnitude of the different causes of anxiety in patients and families, facing surgery. METHODS: Cross-sectional multicenter national survey recruiting 1,260 participants between patients and companions, analyzing the impact of 14 areas selected based on scientific publications aimed at the general public, concerning patients and/or companions, focused on concern about surgery. Patient sex, age, type of surgery (minor/major) and expected inpatient or ambulatory surgery were analyzed. For the companions sex and age, and relationship to patient were analyzed. In both cases it was assessed based on a unidimensional scale of 0 to 10, with 0 being be minimal cause for concern and 10, maximum. RESULTS: The most prominent have been the fear of the unknown, possible complications, the impact on quality of life, the accuracy of diagnosis and possible malignancy of the disease, as well as anesthesia and pain control. There are significant differences in the involvement of patients and companions; and are also differences by sex and age of the patient; type of surgery (minor/major) and expected hospital admission or not. CONCLUSIONS: The patient faces surgery with a number of fears that can be reduced with increased information.

Single-port transanal endoscopic microsurgery: a developing technique.

INTRODUCTION: Transanal endoscopic microsurgery is a widely used and valid technique with established indications. However, the cost of surgical anoscopes is not available in all centers. Many authors have described transanal resection of rectal tumors through a single laparoscopy port such as the SILS system. MATERIALS AND METHODS: We analyzed 5 cases of patients undergoing transanal resection with an SILS device. The clinical, surgical, and oncological data were assessed. RESULTS: The median distance to the anal margin was 7.2 cm (range, 5 to 10 cm) and median tumor size was 3 cm (range, 1 to 6 cm). Median operating time was 75 minutes (range, 60 to 120 min). A postsurgical rectorrhagia occurred in 1 of the case. Two cases were adenocarcinoma, 2 were adenomas, and the other was a mucosa without any tumor remnants. The margins were negative in all cases. CONCLUSIONS: Transanal resection of rectal tumors using the SILS technique is a feasible procedure. Longer series and prospective studies are necessary.

Understanding WHO surgical checklist implementation: tricks and pitfalls. An observational study.

BACKGROUND: The purpose of the present study was to assess the reliability of implementation data regarding the surgical safety checklist (SSC) and to identify which factors influence actual implementation. METHODS: The study was a retrospective record-based evaluation in a regional network of nine Spanish hospitals, combined with a complementary direct-observation study that included a survey of the surgical teams' attitudes. SSC compliance and associated factors were assessed and compared in a retrospective sample of 280 operations and a concurrent sample of another 85 surgical interventions. RESULTS: In the retrospective evaluation the SSC was present in 83.1 % of cases, fully completed in 28.4 %, with 69.3 % of all possible items checked. The concurrent direct-observation study showed that recorded compliance was unreliable (κ < 0.13 for all items) and significantly higher (p < 0.001) than actual compliance. Over-registration occurred across hospitals and surgical specialties. Factors associated with recorded compliance included hospital size, surgical specialty, and the use of an electronic format. In actual (direct-observation) compliance, a positive attitude on the part of the surgeon is an overriding significant factor (OR 12.8), along with using the electronic format, which is consistently and positively associated with recorded compliance but negatively related to actual compliance. CONCLUSIONS: Recorded SSC compliance may be widely unreliable and higher than actual compliance, particularly when recording is facilitated by using an electronic format. A positive attitude on the part of the surgical team, particularly surgeons, is associated with actual compliance. Effective use of the SSC is a far more complex adaptive process than the usual mandatory strategy.