A novel Classification of Intraoperative Adverse Surgical Events (CiASE) in gynaecological surgery
Intraoperative Adverse Events (iAE) during surgery can lead to a long hospital stay and further, subsequent complications for the patient. They can also cause sleepless nights and embarrassment for the surgeon. However, as we all know, some complications are much worse than others.
As part of my ongoing medical research into intraoperative complications, this variance of severity is often vividly illustrated.
Take the case where a patient sustained a serosal tear on the bowel or a bladder injury during a hysterectomy. It was recognised and closed with a couple of sutures. The patient required an IDC for a few days and no further dramas happened.
On the other hand, consider the case where a patient who sustained an intraoperative injury to the rectum with faecal contamination that required a bowel diversion (stoma) that needed to be reversed after 2 or 3 months, with hopefully no further complications developing.
Yet, until now, all intraoperative injuries have been counted as one. There has been no differentiation between the levels of severity and patient suffering. Nor has there been any specification that iAE’s with less severe complications far outweigh those with severe complications. It’s unhelpful to put it mildly.
We needed a framework that put patient wellbeing at the centre of iAE documentation and evaluation.
To address this disparity, Dr Simon West, gynaecological oncology fellow and I developed a new Classification system of intraoperative Adverse Surgical Events (CiASE) that is based on the severity and impact of intraoperative complications on patient recovery.
We studied the literature, created this new classification system, then tested and refined it in collaboration with twenty-five expert gynaecological surgeons from 3 countries. We asked surgeons to apply CiASE, first to virtual cases and then finally to real cases.
After 2 years of work, more than 95% of surgeons participating in this research agree on the integrity and utility of the CiASE score.
And we are excited to share with you that CiASE is now exclusively available within the SurgicalPerformance Insights platform. Here is how the 4 iAE grades have been classified.
Grade 0 – The absence of an intraoperative AE
Examples include a conversion from laparoscopy to open in the absence of an AE (e.g., adhesions) or a serosal tear (when mucosa of viscus is not breached).
Grade 1 – Minimal: Intraoperative surgical AE with no or minimal impact on postoperative course or patient outcome (does not prolong LOS). An example would be if an enterotomy (bladder injury; breach of mucosa) that is simply oversewn; or blood loss requiring transfusion without prolonging LOS.
Grade 2 – Moderate: Intraoperative surgical AE impacting on planned postoperative course or outcome for less than 6 weeks. For example, a patient sustains an intraoperative complication at laparoscopy but needs a conversion to laparotomy to fix it. Or a urological injury requiring repair and or stenting with planned delayed cystogram and or delayed IDC/stent removal.
Grade 3 – Severe: Intraoperative surgical AE, associated with unplanned readmission, return to operating theatres or intervention radiology that takes the patient longer than 6 weeks to recover. For example, a patient needs to go back to theatre for more surgery or the patient sustains any disability for longer than 6 weeks.
Grade 4 – Death: Intraoperative or perioperatively of any cause.
How to apply CiASE in SurgicalPerformance
If and when users select an intraoperative complication, a CiASE field pops up and offers you to assign a score from 0 to 4. CiASE applies to both surgical and anaesthetic complications.
It only covers intraoperative complications and the CiASE score is based on the anticipated severity of the iAE at 6 weeks postoperatively.
Examples to decide what CiASE score should be applied are shown in an information field (next to CiASE Score).
There is consensus amongst senior Australian surgeons that not all complications are equally bad.
Some are less harmful and severe to patients than others. Furthermore, our study found that low-impact complications are 3 times more common than high-impact complications, confirming the need for the CiASE Score to provide surgeons and hospitals with a data set that is much more clinically meaningful and relevant to patient outcomes.
Our hope at SurgicalPerformance is that by utilising the CiASE function, you will be able to put intraoperative complications into perspective.
For the majority of intraoperative complications, we need not lose sleep nor be embarrassed.
Further analyses of these data could give us valuable information on how we could transform severe complications (CiASE score 3) into less severe ones (CiASE score 1 or 0).
As always, please feel free to use the new feature in SurgicalPerformance. Our team and I are very keen to discuss whether you find CiASE helpful and we are looking forward to your feedback.