根据克拉维恩-丁多分类法和综合并发症指数,比较并结合三种病历数据来源,确定术后发病率的最佳量化方法。前瞻性研究

IF 1.3 4区 医学 Q3 SURGERY
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引用次数: 0

摘要

目的 分析连续接受大手术的 200 例患者的发病率和死亡率,确定哪种数据源或哪种数据源组合收集的发病率最高,并确定出院报告中反映的发病率的准确性。在综合审查医疗记录、护理记录和特定表格时发现的所有 PC 的总和被视为金标准。根据 Clavien Dindo 分类法和综合并发症指数 (CCI) 对 PC 进行分类:在整个系列中,联合使用这些数据源可将 CCI 的一致性提高 8%-40%,在 PC 患者中的一致性提高 39.1%-89.7%。PC 的正确记录与手术的复杂程度成反比,在复杂程度较高的手术中,合并数据源可将与金标准的吻合程度提高 35%-67.5% 。在 PC 患者中,出院报告的 CDC 和 CCI 与金标准值的吻合程度分别为 46.8% 和 18.2%。
本文章由计算机程序翻译,如有差异,请以英文原文为准。

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

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.

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来源期刊
Cirugia Espanola
Cirugia Espanola SURGERY-
CiteScore
1.20
自引率
21.10%
发文量
173
审稿时长
53 days
期刊介绍: Cirugía Española, an official body of the Asociación Española de Cirujanos (Spanish Association of Surgeons), will consider original articles, reviews, editorials, special articles, scientific letters, letters to the editor, and medical images for publication; all of these will be submitted to an anonymous external peer review process. There is also the possibility of accepting book reviews of recent publications related to General and Digestive Surgery.
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