Michelle C. Cleghorn

Understanding Quality Issues in Your Surgical Department: Comparing the ACS NSQIP With Traditional Morbidity and Mortality Conferences in a Canadian Academic Hospital.

INTRODUCTION Review of surgical complications in traditional morbidity and mortality (M&M) rounds remains an important mechanism to identify and discuss quality-of-care issues. This process relies on case selection by providers; therefore, complications identified for review may differ from those captured in comprehensive quality programs such as the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Additionally, although the ACS NSQIP captures robust data on complications in surgical wards, without strategies to disseminate this information to staff and improve practice, minimal change may result. The objective of this study was to compare complications identified by the ACS NSQIP with those captured in M&M conferences at a large Canadian academic hospital. METHODS Retrospective medical record reviews of all patients admitted to the general surgery unit from March 2012 to March 2013 were reviewed. Number and types of complications were recorded for cases that were both submitted and reviewed in M&M rounds and those cases that were submitted but not reviewed. These complications were compared with those extracted from our local ACS NSQIP database. RESULTS A total of 1348 general surgical procedures were performed. The ACS NSQIP captured complications in 143 patients compared with 58 patients identified for review in M&M rounds. Both the methods identified similar proportions of major and minor complications (ACS NSQIP 52% major, 48% minor; M&M 58% major, 42% minor). More postoperative deaths were entered into the ACS NSQIP (12) than in M&M conferences (8 reviewed and 2 submitted). The ACS NSQIP identified higher proportions of surgical site infections and readmissions. However, M&M conferences captured additional complications in patients who did not undergo surgery and identified potential quality issues in patients who did not ultimately experience an adverse outcome. CONCLUSIONS M&M rounds and the ACS NSQIP provide important and potentially complementary data on surgical quality. Incorporating the ACS NSQIP outcomes data into traditional M&M conferences may help to optimize quality improvement efforts.

The neutrophil-to-lymphocyte ratio predicts major perioperative complications in patients undergoing colorectal surgery

The objective of the study was to evaluate the association between the neutrophil‐to‐lymphocyte ratio (NLR) and the occurrence of perioperative complications in patients undergoing colorectal surgery.

Comparison of robotic and laparoscopic colorectal resections with respect to 30-day perioperative morbidity.

BACKGROUND Robotic surgery has emerged as a minimally invasive alternative to traditional laparoscopy. Robotic surgery addresses many of the technical and ergonomic limitations of laparoscopic surgery, but the literature regarding clinical outcomes in colorectal surgery is limited. We sought to compare robotic and laparoscopic colorectal resections with respect to 30-day perioperative outcomes. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all patients who underwent robotic or laparoscopic colorectal surgery in 2013. We performed a logistic regression analysis to compare intraoperative variables and 30-day outcomes. RESULTS There were 8392 patients who underwent laparoscopic colorectal surgery and 472 patients who underwent robotic colorectal surgery. The robotic cohort had a lower incidence of unplanned intraoperative conversion (9.5% v. 13.7%, p = 0.008). There were no significant differences between robotic and laparoscopic surgery with respect to other intraoperative and postoperative outcomes, such as operative duration, length of stay, postoperative ileus, anastomotic leak, venous thromboembolism, wound infection, cardiac complications and pulmonary complications. On multivariable analysis, robotic surgery was protective for unplanned conversion, while male sex, malignancy, Crohn disease and diverticular disease were all associated with open conversion. CONCLUSION Robotic colorectal surgery has comparable 30-day perioperative morbidity to laparoscopic surgery and may decrease the rate of intraoperative conversion in select patients.

The accuracy of three predictive models in the evaluation of recurrence rates for gastrointestinal stromal tumors.

Treatment decisions for gastrointestinal stromal tumors (GIST) are frequently guided by tumor characteristics. An accurate prediction of recurrence is important to determine the benefit from targeted therapy. Our goal was to compare the concordance of three validated risk stratification schemes with observed outcomes in patients undergoing resection for GISTs.

The Surgeon Cost Report Card: A Novel Cost-Performance Feedback Tool

What Is the Innovation? We developed a novel cost-performance feedback tool to provide surgeons with a continuous assessment of operating room expenditures. This “Surgeon Cost Report Card” is an email message meant to increase surgeons’ awareness of costs and encourage changes in behavior (Figure). A smartphone-compatible design maximizes usability. Cost data are aggregated and subdivided by item categories. Individual and collective averages are presented, promoting comparison with derived group standards by time period and procedure type. Intuitive color-coding is used to direct attention. It also reinforces the goal of cost reduction, taking advantage of the competitive culture intrinsic to surgical practice. Positive feedback is given by naming the best performer in the group, further encouraging healthy peer-to-peer competition. Privacy is protected by customizing the report card for individual surgeons. The report interval can be freely adjusted based on case volume to balance timely feedback with adequate sample size. Automation of the data processing required to generate the report card enables rapid deployment with minimal administrative requirements.

Is quality important to our patients? The relationship between surgical outcomes and patient satisfaction

Background With greater transparency in health system reporting and increased reliance on patient-centred outcomes, patient satisfaction has become a priority in delivering quality care. We sought to explore the relationship between patient satisfaction and short-term outcomes in patients undergoing general surgical procedures. Methods Satisfaction surveys were distributed to patients following discharge from the general surgery service at an academic hospital between June 2012 and March 2015. Short-term clinical outcomes were obtained from the American College of Surgeons National Surgical Quality Improvement Program database. Patients rated their level of satisfaction on a 5-point Likert scale, and ordered logistic regression model was used to determine predictors of high patient satisfaction. Results 757 patient satisfaction surveys were completed. The mean age of patients surveyed was 52.2 years; 60.0% of patients were female. The majority of patients underwent a laparoscopic procedure (85.9%) and were admitted as inpatients following surgery (72%). 91.5% of patients rated satisfaction of 4–5, and 95.0% said they would recommend the service. The odds of overall satisfaction were lower in patients who had complications (OR: 0.52, 95% CI 0.31 to 0.87) and 30-day readmission (OR: 0.35, 95% CI 0.17 to 0.70). Having elective surgery was associated with higher odds of satisfaction (OR: 1.62, 95% CI 1.07 to 2.47). Conclusions We found a significant association between patient satisfaction and both 30-day readmission and the occurrence of postoperative surgical complications. Given this association, further study is warranted to evaluate patient satisfaction as a healthcare quality indicator.

Comparison of two novel staging systems with the TNM system in predicting stage III colon cancer survival

Adaptations of the TNM staging system that incorporate the Lymph Node Ratio (LNR) have been proposed for stage III colon cancer. This study compared the concordance of two novel staging systems and the TNM system with observed survival outcomes in stage III patients.

Robotic simultaneous resection of rectal cancer and liver metastases

Surgical resection is the only potential cure for colorectal cancer with synchronous liver metastases (SLM). Simultaneous resection of colorectal cancer and SLM using robotic‐assistance has been rarely reported. We demonstrate that robotic‐assisted simultaneous resection of colorectal cancer and SLMs is feasible, safe, and has potential to demonstrate good oncologic outcomes.