A Survey of Surgeons' Perceptions of Defining and Recording Complications Associated With Elective, Emergency and Non-Operative Surgical Admissions.

Abstract

The Clavien-Dindo (CD) classification, derived in elective surgery, limits complications to deviations from the post-operative course. The interpretation of this definition has not been examined. The application of the CD definition to emergency general surgery (EGS) is limited as many EGS patients have a pre/non-operative component of care allowing under-capture of adverse events that are relevant to quality of surgical care. This study aimed to explore how surgeons interpret and define complications across elective and EGS settings. We conducted a cross-sectional survey of 76 general surgeons across four Melbourne public hospitals. With reference to 43 clinical vignettes spanning pre-operative, intra-operative, post-operative, post-discharge, and non-operative care domains respondents indicated whether events constituted complications under the CD classification. The response rate was 72% and 93% of respondents reported EGS experience. Acceptance of individual events ranged from 15% (post-operative fever) to 100% (intra-operative neuropraxia). There was broad acceptance that events occurring during pre-operative and non-operative care could be classified as complications. Minor physiological changes and events not requiring intervention were often disregarded as complications. Perceived accountability influenced responses, with complications more likely to be recognized when linked directly with surgical care. Agreement on classification was only fair (Fleiss' Kappa = 0.254), indicating only fair concordance in complication classification. This study demonstrates significant variability in the classification of surgical complications within EGS, highlighting the limitations of current frameworks particularly in the acute contexts. Incorporating surgeon perspectives into refined classification systems may improve audit accuracy, better capture the complexity of EGS, and ultimately enhance patient care.