Measuring surgical complications

Refining documentation to improve outcomes

From the 2013 Department of Surgery Annual Report

HPB SurgeonsWashington University surgeons have developed a standardized grading system for documenting surgical complications — both their severity and type — and have used it for the past two years to identify, prioritize and address complications of the Whipple procedure, performed above by Steven Strasberg, MD, left, and David Linehan, MD.KEEPING COMPLICATIONS LOW for complex surgeries is an essential goal for surgeons and hospitals wanting to improve the quality of patient care. Washington University hepatobiliary-pancreatic and GI (HPB-GI) surgeons have focused not only on making surgeries safer at Barnes-Jewish Hospital, but also on improving how complications are measured, an important step in addressing post-surgical problems.

In 1992, while at the University of Toronto, Steven Strasberg, MD, and colleagues proposed a classification of negative outcomes of surgery and a severity grading system for complications. Their reasoning was that the severity — as well as the type — of complications should be clearly and consistently reported. Several years ago, Strasberg and fellow Washington University HPB-GI surgeons David Linehan, MD, and William Hawkins, MD, proposed a modified scale, called the Accordion Severity Grading System, which can be adapted to studies of different sizes and complexity.

Strasberg has used the Accordion System to measure complications of the Whipple procedure — the definitive operation for cancer of the head of the pancreas — in patients at Barnes-Jewish Hospital. The surgery, which 70 years ago had a 31 percent mortality rate, has become safer because of advances in surgery, anesthesia and intensive care. The Accordion results at Barnes-Jewish were no deaths and only three patients out of 100 with higher-level complications graded as 4 or 5 on a scale of 1-6.

“We have tracked complications for the Whipple procedure since August 2011, and our data thus far are outstanding,” says Strasberg. “But we did find complications that are not so severe, and we need to turn our attention to them.”

To study complications, Strasberg has also worked closely with Bruce Hall, MD, PhD, MBA, a Washington University endocrine surgeon who serves as the Barnes-Jewish champion of the American College of Surgeons National Surgical Quality Improvement Program and director of modeling and evaluation for the national effort. In two studies, they worked with 43 surgical experts to quantify the severity of postoperative complications, developed a morbidity index for procedures, and devised a method for comparing the relative weight of complications for a given procedure.

“For the Whipple procedure, intra-abdominal abscesses represent 30 percent of the burden,” says Strasberg. “That’s important because once we know the burden of a complication, we know that’s where we have to concentrate our efforts.”