Accuracy of surgical complication rate estimation using ICD-10 codes.

BACKGROUND: The ICD-10 codes are used globally for comparison of diagnoses and complications, and are an important tool for the development of patient safety, healthcare policies and the health economy. The aim of this study was to investigate the accuracy of verified complication rates in surgical admissions identified by ICD-10 codes and to validate these estimates against complications identified using the established Global Trigger Tool (GTT) methodology. METHODS: This was a prospective observational study of a sample of surgical admissions in two Norwegian hospitals. Complications were identified and classified by two expert GTT teams who reviewed patients' medical records. Three trained reviewers verified ICD-10 codes indicating a complication present on admission or emerging in hospital. RESULTS: A total of 700 admissions were drawn randomly from 12 966 procedures. Some 519 possible complications were identified in 332 of 700 admissions (47·4 per cent) from ICD-10 codes. Verification of the ICD-10 codes against information from patients' medical records confirmed 298 as in-hospital complications in 141 of 700 admissions (20·1 per cent). Using GTT methodology, 331 complications were found in 212 of 700 admissions (30·3 per cent). Agreement between the two methods reached 83·3 per cent after verification of ICD-10 codes. The odds ratio for identifying complications using the GTT increased from 5·85 (95 per cent c.i. 4·06 to 8·44) to 25·38 (15·41 to 41·79) when ICD-10 complication codes were verified against patients' medical records. CONCLUSION: Verified ICD-10 codes strengthen the accuracy of complication rates. Use of non-verified complication codes from administrative systems significantly overestimates in-hospital surgical complication rates.

Great variation between ICU physicians in the approach to making end-of-life decisions.

INTRODUCTION: End-of-life (EOL) decision-making in the intensive care unit (ICU) is difficult, but is rarely practiced in simulated settings. We wanted to explore different strategies ICU physicians use when making EOL decisions, and whether attitudes towards EOL decisions differ between a small-group simulation setting and a large-group plenary setting. METHODS: The study took place during a Scandinavian anaesthesiology and intensive care conference. The simulated ICU patient had a cancer disease with a grave prognosis, had undergone surgery, suffered from severe co-morbidities and had a son present demanding all possible treatment. The participants were asked to make a decision regarding further ICU care. We presented the same case scenario in a plenary session with voting opportunities. RESULTS: In the simulation group (n = 48), ICU physicians used various strategies to come to an EOL decision: patient-oriented, family-oriented, staff-oriented and regulatory-oriented. The simulation group was more willing than the plenary group (n = 47) to readmit the patient to the ICU if the patient again would need respiratory support (32% vs. 8%, P < 0.001). Still, fewer participants in the simulation group than in the plenary group (21% vs. 38%, P = 0.019) considered the patient's life expectancy of living an independent life to be over 10%. CONCLUSION: There was great variation between ICU physicians in the approach to making EOL decisions, and large variations in their life expectancy estimates. Participants in the simulation group were more willing to admit and readmit the patient to the ICU, despite being more pessimistic towards life expectancies. We believe simulation can be used more extensively in EOL decision-making training.

A comparison of SAPS II and SAPS 3 in a Norwegian intensive care unit population.

BACKGROUND: Simplified Acute Physiology Score (SAPS II) is the most widely used general severity scoring system in European intensive care medicine. Because its performance has been questioned in several external validation studies, SAPS 3 was recently released. To our knowledge, there are no published validation studies of SAPS II or SAPS 3 in the Scandinavian countries. We aimed to evaluate and compare the performance of SAPS II and SAPS 3 in a Norwegian intensive care unit (ICU) population. METHOD: Prospectively collected data from adult patients admitted to two general ICUs at two different hospitals in Norway were used. Probability of mortality was calculated using the SAPS 3 global equation (SAPS 3 G), the SAPS 3 Northern European equation (SAPS 3 NE), and the original SAPS II equation. Performance was assessed by the standardized mortality ratio (SMR), area under receiving operating characteristic, and the Hosmer and Lemeshow goodness-of-fit C test. RESULTS: One thousand eight hundred and sixty-two patients were included after excluding readmissions, and patients who were admitted after coronary surgery or burns. The SMRs were SAPS 3 G 0.71 (0.65, 0.78), SAPS 3 NE 0.74 (0.68, 0.81), and SAPS II 0.82 (0.75, 0.91). Discrimination was good in all systems. Only the SAPS 3 equations displayed satisfactory calibration, as measured by the Hosmer-Lemeshow test. CONCLUSION: The performance of SAPS 3 was satisfactory, but not markedly better than SAPS II. Both systems considerably overestimated mortality and exhibited good discrimination, but only the SAPS 3 equations showed satisfactory calibration. Customization of these equations based on a larger cohort is recommended.

[Emergency dialysis at Haukeland hospital in 1999]. / Akutt dialysebehandling ved Haukeland Sykehus i 1999.

BACKGROUND: The incidence of acute renal failure requiring dialysis is not known in our country. The criteria for acute dialysis are not uniformly accepted, neither is there consensus on dialysis strategy in critically ill patients. We describe the acute dialysis activity in our hospital in 1999. MATERIAL AND METHODS: We have retrospectively recorded the indications for dialysis and the course and hospital mortality in all patients treated with acute dialysis in 1999. RESULTS: 108 patients were treated with 670 dialysis procedures; the incidence was 20.5 per 100,000 inhabitants. Continuous veno-venous haemodiafiltration accounted for 37% of all treatments. In 50% of the patients acute renal failure occurred after surgery or serious infections with a mortality of 57% and 62% respectively. Total dialysis mortality was 45%. The mortality in patients with malignancy and peripheral vascular disease was 90% and 75% respectively. 10% of the patients needed chronic dialysis. INTERPRETATION: The incidence of acute dialysis was higher than previously reported from European countries and may be related to the general increase in active treatment of patients with complicated diseases. The mortality rates are persistently high. Close cooperation between nephrologists and intensivists in the treatment of these patients is essential.

Errors in the intensive care unit (ICU). Experiences with an anonymous registration.

BACKGROUND: In order to obtain information about the occurrence and severity of errors in an ICU, this investigation was conducted in a combined ICU and postoperative ward at a Norwegian University Hospital. METHODS: An anonymous registration was conducted in order to reveal as many as possible of all errors in the unit. A separate registration form was used, recording the type of error, date and time, sex and age of the patient, patient condition (unstable/stable) and where the error occurred (on the ward or during transport). The registration started in October 1995, and reports until November 1996 are included (13 months). Consequences of the errors were graded using a 6-point scale (0=no consequences and 5=fatal). Two experienced intensivists and two experienced ICU nurses independently evaluated the errors using a visual analogue scale (VAS) with 10 as the worst imaginable error. All four were blinded to consequences of the error. RESULTS: A total of 87 errors was reported: 36 (41.3%) were medication errors, 17 (19.5%) related to intravenous infusions, 15 (17.2%) were due to technical equipment failure, and the rest (19 errors, 21.8%) miscellaneous. No consequences could be detected in 55 cases (63%) (grade 0). Six errors were graded as 1, and 22 (25%) as grade 2 (therapeutic intervention necessary, no damage recorded). Five errors had more serious consequences, and one was fatal. The scoring of errors varied a great deal. Mean VAS score was 4.2 (SD 1.7). The sum of VAS score (max. 40) on each error followed a normal distribution, and 12 errors had a score >25. CONCLUSION: Errors happen frequently in the ICU. Probably, our data do not represent the true incidence of errors in the period, which we believe was higher. Many errors are graded as serious or severe, but still have limited consequences for the patient.

Puncture technique and postural postdural puncture headache. A randomised, double-blind study comparing transverse and parallel puncture.

BACKGROUND: This clinical study was conducted in order to investigate the effect of two different orientations of the bevel during dural puncture on development of postural postdural puncture headache (PPDPH). METHODS: Two hundred and eighteen patients aged 18 to 50 years scheduled for minor non-obstetric surgery using spinal anaesthesia (SA) were included in this randomised, double-blind study. Dural puncture was performed using a 0.42 mm O.D. (27-g) Quincke spinal needle with the orientation of the bevel parallel or transverse relative to the longitudinal axis of the dural cylinder. All patients were blinded with regard to the puncture technique, and so was the anaesthesiologist performing a telephone interview 5 to 7 days postoperatively. The occurrence and duration of headache, backache and other complaints were recorded. Headache was classified as PPDPH or non-PPDPH, and intensity of the headache was registered using a numerical rating scale (NRS) from 0 to 10. RESULTS: Two hundred and twelve patients with a mean age of 35.3 years completed the study, 106 in each group. The two groups were comparable with regard to mean age, sex, local anaesthetics used and surgical procedure performed. Headache occurred in 44 patients postoperatively. PPDPH was diagnosed in 4/106 patients (3.8%) in the parallel group and 24/106 (22.6%) in the transverse group (P < 0.0002). Postoperative backache occurred in 31 and 20 patients (parallel compared to transverse) (NS). CONCLUSIONS: Dural puncture with the bevel of the needle transverse to the longitudinal axis of the dural cylinder gave significantly more cases of PPDPH than puncture with the bevel parallel to this axis even when using a 27-g Quincke needle. When using Quincke bevelled needles care must be taken to assure that the orientation of the bevel is parallel to the longitudinal axis of the dural sac.

Postural post-dural puncture headache after spinal and epidural anaesthesia. A randomised, double-blind study.

BACKGROUND: This study was conducted in order to investigate the effect of patient expectation in the development of postural post-dural puncture headache (PPDPH). METHODS: 224 patients less than 55 years scheduled for minor non-obstetric surgery were randomised to receive single-injection spinal (SA) or epidural (EA) anaesthesia. A 27-g Quinke needle was used for SA and a 18-g Tuohy needle for EA. Patients, operating team and postoperative ward personnel were all blinded to the anaesthetic given and so was an independent observer responsible for follow-up after 5-7 days. The occurrence of headache, backache and other complaints was recorded. Headache was classified as PPDPH or non-PPDPH, and duration and intensity of the headache was registered. The quality of anaesthesia was directly evaluated by the surgeon using a VAS scale from 1 (excellent) to 10 (very poor) and indirectly by the supplemental use of opioid analgesia and general anaesthesia in the two groups. RESULTS: 212 patients, 103 SA and 109 EA, with a mean age of 36.7 years, could be fully evaluated. The groups were comparable with regards to age, sex and surgical procedure performed. Headache occurred in 44 patients postoperatively. PPDPH was diagnosed in 16 patients (15.5%) in the SA group and 2 (1.8%) in the EA group (P = 0.0014). Non-PPDPH occurred in 13 patients in each group. PPDPH had significantly greater mean intensity and duration than non-PPHPH. More patients in the EA group had postoperative backache (31.2%) than in the SA group (22.3%), but this difference was not statistically significant. More patients in the EA received general anaesthesia and opioid analgesia than in the SA group, and the surgeon's rating was on average 1.3 in the SA group compared to 2.5 in the EA group (P = 0.0003). CONCLUSIONS: SA gave more headache but superior quality of surgical anaesthesia compared with EA. Dural puncture, and not expectation, is the major cause of PPDPH.

Surgery during inhalation with nitric oxide in a patient with severe adult respiratory distress syndrome (ARDS).

Nitric oxide (NO) is increasingly used in intensive care units (ICU) in order to treat serious hypoxaemia secondary to ARDS. Since interrupting NO delivery in such patients for more than a few minutes could lead to serious adverse events, moving the patient outside the ICU has been very difficult. Recently developed equipment (Noresc 1503) enabled us to deliver 10 or 20 ppm NO from a ventilatory bag with reservoir. This is used for ventilation under transport from the ICU to the operating theatre (OT) or radiology department. We present a patient with severe ARDS undergoing major surgery while being treated with NO. The patient could be moved to the OT and operated on during five hours without significant changes in vital functions.

Central venous catheter with subcutaneous injection port (Port-A-Cath): 8 years clinical follow up with children.

Long-term intermittent venous access was established in 77 children by means of a central venous catheter (CVC) with a subcutaneous injection port (Port-A-Cath; PAC). Seventy of these children were included in this follow-up study. Sixty-three were treated for different malignant diseases, five for cystic fibrosis, one for severe hemophilia and one for central nervous system disease with seizures as the main problem. As of April, 1992, PACs had been in place for 3/12 to 8 3/12 years (cumulative 175 5/12 years) with 2,206 entries into the system. The PACs were used for blood sampling and administration of chemotherapy, antibiotics, fluids, total parenteral nutrition (TPN) and blood products. Portal infection was observed in four patients of which two patients had their PAC removed. Catheter dislocation was observed in two and catheter breakage in one. Portal occlusion, extravasation, thrombosis leading to removal of the PAC or other technical or psychological complications were not observed. The children continued normal activities, and the easy venous access decreased emotional stress during treatment. Local doctors were trained to use PACs, through which they administered maintenance chemotherapy. We conclude that long-time use of PACs in children is safe and has many advantages compared to traditional CVCs in use. Strict indications, meticulous implantation techniques and adequate handling are, however, mandatory.

Central venous catheter with subcutaneous injection port (Port-A-Cath): clinical experience with children.

Long-term intermittent venous access was established in 26 children by means of a central venous catheter (CVC) with a subcutaneous injection port (Port-A-Cath) (PAC). As of December, 1985, PACs had been in place for 20-750 days (cumulative 10,890 days) with 647 entries into the system. The PACs were used for blood sampling and administration of chemotherapy, antibiotics, fluids, total parenteral nutrition (TPN), and blood products. One patient with sever neutropenia (absolute neutrophil granulocyte count [ANC] less than 0.1 x 10(9)/L) at the time of the PAC implant developed an infection around the port after 2 days, with subsequent septicemia (Bacillus cereus) necessitating removal of the PAC. Otherwise, no definite PAC-related infections occurred, including 258 days of neutropenia (ANC less than 0.5 x 10(9)/L). Two PACs were found occluded with greyish deposits of fat and organic material after long-term (45 and 61 days) continuous TPN and were removed. Malposition of catheter, extravasation, thrombosis, and other potential technical or psychological complications were not observed. The children continued normal activities, and the easy venous access decreased emotional stress during treatment. Local doctors were trained to use the PACs, with which they administered maintenance chemotherapy. We conclude that the use of PACs in children is safe, even in the first year of life, and has many advantages when compared with other CVCs currently in use. Strict indications, meticulous implantation technique, and adequate handling are, however, mandatory.

Spinal anaesthesia for outpatient surgery.

In a prospective study of 51 young male outpatients given spinal anaesthesia through a 25-gauge needle, we found a 37.2% incidence of postdural puncture headache. In addition, 54.9% complained of backache after surgery. Occurrence of headache significantly prolonged the sick-leave from work. General anaesthesia would be preferred by 31.4% of patients for a similar procedure in the future. These patients had a higher incidence of postoperative backache and pain during lumbar puncture. It is concluded that spinal anaesthesia is not a satisfactory technique for outpatient procedures in young men.