Standardized monitoring of adverse events following thoracic surgery is essential to quality improvement

In thoracic surgery, postoperative adverse events (AEs) are too common, ranging from 30-60% and resulting in an increase in morbidity and mortality, length of hospital stay and increased health care costs. The importance of rigorous recording of AEs is widely recognized, yet AE definitions vary widely, inadequate reporting is common and there is a lack of national best-practice recommendations. We have developed a real-time, web-based, point-of-care, software tool (tsqic.org)to collect clinical and OR data, adverse events, quality metrics and assist with clinical documentation with the goal of improving the quality and efficiency of care and communication.

Thoracic surgeons predominantly treat patients with cancer, andthoracic cancers are the most harmful and lethal of all. Thoracic surgery is the cornerstone of curative intent treatment for virtually all chest cancers.⁴⁷ However, given vital thoracic structure and function, postoperative adverse events (AEs) are too common, ranging from 30-60%,^48-51 augmenting risk of mortality,^52-54 impairing recovery,⁵⁵ increasing length of stay (LOS) ^54,55 and readmissions,⁵⁶ impairing patient experience,⁵⁷ and raising health care costs.^54,58 While some AEs inevitably occur, many are preventable and cost the Canadian healthcare system $397 million/year.^59,60 The importance of rigorous recording of AEs is widely recognized, yet AE definitions vary widely, inadequate reporting is common, there is a lack of national best-practice recommendations.^61-66

In partnership with my colleagues within the Ottawa Division of Thoracic Surgery, I led the development of a standardized system to define the presence and severity of all AEs after thoracic surgery (ottawatmm.org) and began capturing all AEs after all thoracic surgeries in 2008.⁵¹ We demonstrated the classification system is feasible,⁵¹ reliable and reproducible,⁶⁷ facilitates objective comparison,⁶⁸ identifies burden of illness of individual complications,^69,70 provides an effective method for continuous surgical quality assessment, provides complementary value to National Surgical Quality Improvement Program,⁶⁸ and has been adopted by numerous surgical groups internationally.^71,72 Building on this research, we designed a real-time, web-based, point-of-care, software tool (tsqic.org) to enable bedside clinical data recording, data storage, and automated quality improvement interventions, including standardized data for M&M rounds, dynamic surgeon anonymized self-assessment and positive deviance (SSA/PD). Implementation and evaluation of this SSA/PD intervention in Ottawa resulted in 25-38% reduction in three AEs³⁷and a qualitative analysis of surgeons’ experience highlighted their favorable reviews regarding the positivistic and patient-centered process.³⁸ In partnership with the Canadian Association of Thoracic Surgeons (CATS), as Director of Research, I co-led the development of multicenter synoptic data recording, reporting and quality improvement interventions, leading to actionable recommendations for the delivery of efficient and effective thoracic surgery, funded through Canadian Partnership Against Cancer ($810k). As of March 2020, 10 thoracic surgery centers are actively collecting identical data for patients receiving care at their center (7 using the TSQIC software we created in Ottawa), 3 more centers are joining by Sept 2020, and another 6 centers are working to join. The 19 centers span 7 provinces, and represent over half of Canadian thoracic surgery centers and two-thirds of Canadian thoracic surgeons. Through this process, we are transforming thoracic surgery nationally, using data-driven methods that highlight best practice, and combined with best evidence, lead to consensus recommendations that improve and standardize care.

Relevant papers:

1. Ivanovic J, Maziak DE, Ramzan S, McGuire AL, Villeneuve PJ, Gilbert S, Sundaresan RS, Shamji FM, Seely AJE. Incidence, severity and perioperative risk factors for atrial fibrillation following pulmonary resection. Interact Cardiovasc Thorac Surg 2014 18(3): 340-346.
2. IvanovicJ, Seely AJE, Anstee C, Villeneuve PJ, Gilbert S, Maziak DE, Shamji FM, Forster AJ, Sundaresan RS. Measuring surgical quality: comparison of postoperative adverse events with the american college of surgeons NSQIP and the Thoracic Morbidity and Mortality classification system.  J Am Coll Surg 2014, 218(5): 1024-1031.
3. Liang S, Ivanovic J, Gilbert S, Maziak DE, Shamji FM, Sundaresan RS, Seely AJE. Quantifying the incidence and impact of postoperative prolonged alveolar air leak after pulmonary resection. J Thorac Cardiovasc Surg  2013, 145(4): 948-954.
4. Ivanovic J, Al-Hussaini A, Al-Shehab D, Threader J, Villeneuve PJ, Ramsay T, Maziak DE, Gilbert S, Shamji FM, Sundaresan RS, Seely AJE. Evaluating the reliability and reproducibility of the Ottawa Thoracic Morbidity and Mortality classification system. Ann Thorac Surg 2013, 91(2): 387-393.
5. Seely AJE, Ivanovic J, Threader J, Al-Hussaini A, Al-Shehab D, Ramsay T, Gilbert S, Maziak DE, Shamji FM, Sundaresan RS. Systematic classification of morbidity and mortality after thoracic surgery. Ann Thorac Surg 2010 90(3): 936-942.