Documentation of individualized preoperative risk assessment: a multi-center study

Joshua A Bloomstone,David Walker,Benjamin T Houseman,Gerald A Maccioli,Jessica Curran,Evora Vicents Sande,James Steinshouer,Ann Brantley,Ramani Moonesinghe,Tania Haddad

doi:10.1186/s13741-020-00156-2

Abstract

BackgroundIndividual surgical risk assessment (ISRA) enhances patient care experience and outcomes by informing shared decision-making, strengthening the consent process, and supporting clinical management. Neither the use of individual pre-surgical risk assessment tools nor the rate of individual risk assessment documentation is known. The primary endpoint of this study was to determine the rate of physician documented ISRAs, with or without a named ISRA tool, within the records of patients with poor outcomes. Secondary endpoints of this work included the effects of age, sex, race, ASA class, and time and type of surgery on the rate of documented presurgical risk.MethodsThe records of non-obstetric surgical patients within 22 community-based private hospitals in Arizona, Colorado, Nebraska, Nevada, and Wyoming, between January 1 and December 31, 2017, were evaluated. A two-sample proportion test was used to identify the difference between surgical documentation and anesthesiology documentation of risk. Logistic regression was used to analyze both individual and group effects associated with secondary endpoints.ResultsSeven hundred fifty-six of 140,756 inpatient charts met inclusion criteria (0.54%, 95% CI 0.50 to 0.58%). ISRAs were documented by 16.08% of surgeons and 4.76% of anesthesiologists (p < 0.0001, 95% CI −0.002 to 0.228). Cardiac surgeons documented ISRAs more frequently than non-cardiac surgeons (25.87% vs 16.15%) [p = 0.0086, R-squared = 0.970%]. Elective surgical patients were more likely than emergency surgical patients (19.57 vs 12.03%) to have risk documented (p = 0.023, R-squared = 0.730%). Patients over the age of 65 were more likely than patients under the age of 65 to have ISRA documentation (20.31 vs 14.61%) [p = 0.043, R-squared = 0.580%]. Only 10 of 756 (1.3%) records included documentation of a named ISRA tool.ConclusionsThe observed rate of documented ISRA in our sample was extremely low. Surgeons were more likely than anesthesiologists to document ISRA. As these individualized risk assessment discussions form the bedrock of perioperative informed consent, the rate and quality of risk documentation must be improved.

Highlights

Individual surgical risk assessment (ISRA) enhances patient care experience and outcomes by informing shared decision-making, strengthening the consent process, and supporting clinical management
The current calculator is based on a multivariate analysis of 4.3 million surgical episodes that have been entered in the National Surgical Quality Improvement (NSQIP) database between 2013 and 2017, and provides patientspecific risk for 18 different potential outcomes that could occur within 30 days following one of 1557 surgical procedures (Cohen et al, 2017; American College of Surgeons National Surgical Quality Improvement Program, 2019)
The rate of cardiac arrest in our study (22:10,000) was much higher than the 5.6:10,000 reported by the National Anesthesia Clinical Outcomes Registry (NACOR). We believe this difference exists because NACOR only includes cardiac arrests that happen within a narrow perioperative window, where as we counted all cardiac arrests from the time of anesthetic induction to the end of hospital stay

Summary

Introduction

Individual surgical risk assessment (ISRA) enhances patient care experience and outcomes by informing shared decision-making, strengthening the consent process, and supporting clinical management. As such, individualized surgical risk assessments represent a National Quality Strategy surgical measure and are required by both medical societies and regulatory bodies (American Society of Anesthesiology, 2019; American College of Surgeons, 2019; American Medical Association Measure#358, 2019). Several validated individualized surgical risk assessment (ISRA) tools are readily available to assist physicians in accurately relaying surgical risk information to patients. These include SORT (Wong et al, 2017), POSSUM (Copeland et al, 1991), p-POSSUM (Prytherch et al, 1998), and the American College of Surgeons (ACS) risk calculator (Bilimoria et al, 2013). The current calculator is based on a multivariate analysis of 4.3 million surgical episodes that have been entered in the National Surgical Quality Improvement (NSQIP) database between 2013 and 2017, and provides patientspecific risk for 18 different potential outcomes that could occur within 30 days following one of 1557 surgical procedures (Cohen et al, 2017; American College of Surgeons National Surgical Quality Improvement Program, 2019)

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Discussion

Conclusion