CATS DB TSQIC
Ottawa
TM&M

The Ottawa Thoracic Morbidity & Mortality System
Classifying Thoracic Surgical Complications

  • Mission
  • We aim to improve quality of thoracic surgical care by enabling continuous quality improvement through standardized, comprehensive, collegial capturing, classifying, reporting, analyzing and monitoring of the presence and severity of surgical complications.
  • The Ottawa TM&M System
  • Objective reporting of post-operative adverse events (AEs) is the basis of surgical quality assurance. As such, data on post-operative AEs are often used as a means of comparing surgical techniques, individual surgeon outcomes, and institutional performance.1 Unfortunately, proper documentation and monitoring of post-operative AEs is imprecise and lacks objectivity because of often subjective impressions. Furthermore, conclusive assessments of surgical quality have remained limited by the lack of agreement on how to define and classify complications by severity.2

    In 1992, Clavien and colleagues were the first to introduce the concept of severity grading of post-operative AEs.3 The principle underlying this classification is that the severity of an AE is proportional to its impact on a patient and the degree of effort to rectify it. The rationale for this approach was to eliminate subjective interpretation of serious AEs and any tendency to down-grade complications, as it is based on data that are well documented and easily verified. The system, now known as the Clavien-Dindo classification of post-operative AEs, was validated in 2004 in a large cohort of general surgical patients,4 and has since been used in a number of different surgical sub-specialities.5-9

    In 2008, modeled on the Clavien-Dindo system, The Ottawa Hospital’s Division of Thoracic Surgery developed a standardized approach to identify both presence and severity of Thoracic Morbidity & Mortality (TM&M), with the aim to capture all AEs after all surgeries.10 The rigorous implementation in clinical practice and evaluation of such a system requires time. Since its inception, supporting studies have shown that the TM&M classification is feasible,10 reliable and reproducible - as demonstrated through a national survey of the Canadian Association of Thoracic Surgeons,11 facilitates objective comparison, identifies burden of specific complications,12-13 provides an effective method for continuous surgical quality assessment, and serves as a complement to the gold standard, the National Surgical Quality Improvement Program (NSQIP).14 More recently, the TM&M classification has been adopted by numerous surgical groups internationally.15-16 We are also aware of randomized trials, which have included the TM&M classification in their end point evaluation.17
    References
    1. Veen EJ, Steenbruggen J, Roukema JA. Classifying surgical complications: A critical appraisal. Arch Surg 2005;140:1078−83.
    2. Martin RC, 2nd, Brennan MF, Jaques DP. Quality of complication reporting in the surgical literature. Ann Surg 2002;235:803−13.
    3. Clavien PA, Sanabria JR, Strasberg SM. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surg 1992;111:518−26.
    4. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205−13.
    5. DeOliveira ML, Winter JM, Schafer M, et al. Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg 2006;244:931−37.
    6. Gonzalgo ML, Pavlovich CP, Trock BJ, et al. Classification and trends of perioperative morbidities following laparoscopic radical prostatectomy. J Urol 2005;174:135−39.
    7. Kocak B, Koffron AJ, Baker TB, et al. Proposed classification of complications after live donor nephrectomy. Urology 2006;67:927−31.
    8. Mazeh H, Samet Y, Abu-Wasel B, et al. Application of a novel severity grading system for surgical complications after colorectal resection. J Am Coll Surg 2009;208:355−61.
    9. Tamura S, Sugawara Y, Kaneko J, et al. Systematic grading of surgical complications in live liver donors according to Clavien's system. Transpl Int 2006;19:982−87.
    10. Seely AJE, Ivanovic J, Threader J, et al. Systematic classification of morbidity and mortality after thoracic surgery. Ann Thor Surg 2010;90:936‒42.
    11. Ivanovic J, Threader J, Alhussaini A, et al. Testing the reliability and reproducibility of the Ottawa Hospital Thoracic Morbidity and Mortality classification system. Ann Thor Surg 2011;91:387‒93.
    12. Liang S, Ivanovic J, Gilbert S, et al. Quantifying the incidence and impact of postoperative prolonged alveolar air leak after pulmonary resection. J Thorac Cardiovasc Surg 2013;145:948‒54.
    13. Ivanovic J, Ramzan S, McGuire AL, et al. Incidence, severity and perioperative risk factors for atrial fibrillation following pulmonary resection. Interact Cardiovasc Thorac Surg 2014;18:340‒46.
    14. Ivanovic J, Seely AJE, Anstee C, et al. 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 Surg2014;218;1024‒31.
    15. Salati M, Pompili C, Refai M, et al. The use of the Thoracic Morbidity and Mortality system for the internal analysis of performance: A case-matched temporal audit. Eur J Cardiothorac Surg 2014;45:859‒63.
    16. Salati M, Refai M, Pompili C, et al. Major morbidity after lung resection: A comparison between the European Society of Thoracic Surgeons Database system and the Thoracic Morbidity and Mortality system. J Thorac Dis 2013;5:217‒22.
    17. Infante M, Chiesa G, Solomon D, et al. Surgical procedures in the DANTE trial: A randomized study of lung cancer early detection with spiral computed tomography: Comparative analysis in the screening and control arm. J Thorac Onc 2011;6:327‒35.
  • Our Team
  • The Thoracic Research Team is located at the Ottawa Hospital General Campus in Ottawa, Canada. The research team is a multidisciplinary team, consisting of thoracic surgeons and residents, graduate students, and research and support staff and is under the direction of Dr. Andrew Seely.

    Andrew JE Seely, MD PhD FRCSC
    Ottawa Hospital - General Campus
    501 Smyth, Box 708, Ottawa, Ontario, K1H 8L6
    Tel: 613-737-8899 x74032
    Fax: 613-737-8668
    aseely@ohri.ca

    Caitlin Anstee
    Database Manager and Software Developer
    Division of Thoracic Surgery, Department of Surgery, The Ottawa Hospital
    canstee@ohri.ca

    Ottawa Division of Thoracic Surgery
    Sebastien Gilbert, MD FRCSC
    sgilbert@ohri.ca
    Donna E. Maziak, MDCM MSc FRCSC FACS
    dmaziak@ohri.ca
    Farid Shamji, MBBS FRCSC
    fshamji@ohri.ca
    Sudhir Sundaresan, MD FRCSC FACS
    ssundaresan@ohri.ca
    Patrick James Villeneuve, MDCM PhD FRCSC
    pvillenevue@ohri.ca
  • Affiliations






  • Ottawa TM&M Definitions
  • Select a system, a complication & a grade below:

    Please note, revised definitions will appear in yellow to indicate what has changed to allow for compatibility with other complication systems.

    • General Description
    • Breakdown of a suture line in a surgical anastomosis with leakage of gastric or intestinal fluid
    • Grade Specific Description
    • Transient or equivocal, no therapy added
  • Overall Classification System
  • As per the Clavien system, the following definition of complication and overall classification scheme was used to describe any deviation from the normal postoperative course:
  • Minor
  • Grade I
    Any complication without need for pharmacologic treatment or other intervention.
  • Grade II
    Any complication that requires pharmacological treatment or minor intervention only.
  • Major
  • Grade IIIa
    Any complication that requires surgical, radiological, endoscopic intervention, or multi-therapy - Intervention does not require general anaesthesia.
  • Grade IIIb
    Any complication that requires surgical, radiological, endoscopic intervention, or multi-therapy - Intervention requires general anaesthesia.
  • Grade IVa
    Any complication requiring ICU management and life support - Single organ dysfunction.
  • Grade IVb
    Any complication requiring ICU management and life support - Multi-organ dysfunction.
  • Grade V
    Any complication leading to the death of the patient.
  • Other Quality Indicators and Complication Modifiers
  • All of the complications defined in the Ottawa TM&M System can be modified by the following descriptors:

    · Prolonged Length of Stay

    · Resulted in Readmission

    · Resulted in Return to Emerg or Clinic

    · Resulted in Unplanned Transfer to ICU

    · Resulted in Unplanned Transfer to Step-Down Unit

    · Resulted in Tracheostomy

    · Resulted in Reintubation

    · Complication Not Related to Procedure

    · Discharged with Chest Tube

    · Discharged with Home O2
  • The Harmonization Process
  • The definition of each AE as described by their respective database was reviewed and compatibility was assessed with those defined by the CATS system. Data elements were classified as “Perfect”, “Good”, or “Non-Harmonized based on their degree of harmonization. Harmonization of the CATS system was achieved through the addition of 17 adverse events and 2 complication modifiers.
  • New Adverse Events
  • System
    Complication
  • Cardiovascular
    Cardiac Arrest Requiring CPR
  • Gastrointestinal
    C-Diff
  • Gastrointestinal
    Feeding J-Tube Complication
  • Gastrointestinal
    Liver Dysfunction
  • Gastrointestinal
    Pancreatitis
  • Gastrointestinal
    Pyloromyotomy/Pyloroplasty Complication
  • Gastrointestinal
    Small Bowel Obstruction
  • Gastrointestinal
    Stricture
  • Gastrointestinal
    Intraabdominal Bleeding
  • Gastrointestinal
    Acute Diaphragmatic Hernia
  • Gastrointestinal
    Intraabdominal Abscess
  • Neurological
    Delirium Tremens
  • Pulmonary
    Acute Aspiration
  • Pulmonary
    Pulmonary Abscess
  • Other
    Anemia or Anemia Requiring Transfusion
  • Other
    Bacteremia or Bacteremic Shock
  • Other
    Central Line Infection
  • New Modifiers
  • Discharged with Chest Tube
  • Discharged with Home O2
  • Harmonization with Other Systems
  • The Ottawa Thoracic Morbidity & Mortality (TM&M) Classification System has been updated - adding two new complication modifiers and seventeen new adverse event definitions to allow mapping to the following international systems: STS, ESTS, ACS-NSQIP and ECCG. .
  • TSQIC - Volume & Quality Monitoring
  • Recognizing that software was necessary to efficiently record and review TM&M data, as well as to report the data back to surgeons, iterative development led to an evolution of a secure, real-time, web-based, point-of-care, iPad-optimized Thoracic Surgery Quality monitoring, Information management, and Clinical documentation (TSQIC) software system.

    TSQIC is divided into three components: i) Mandatory OR, for prospective collection of all thoracic surgical cases within the practice, and TM&M, for tracking all complications associated with the operative procedures performed; ii) automated and dynamic reporting of statistics for surgical volume and quality; and iii) clinical documentation for preoperative clinic consults, operative reports, daily progress notes for admitted patients, and follow-up notes.

    Data collection is a continuous, collegial and divisional activity that is comprised of daily reporting (by thoracic surgical residents and fellows), weekly review (by staff surgeons) to facilitate uniform classification of complications, monthly discussion at morbidity & mortality (M&M) rounds (by the entire division), and quarterly analysis.

    Accurate measurement of post-operative adverse events is necessary, but not sufficient for quality improvement, without also providing surgeons with information and the infrastructure on how to improve patient outcomes.

    Bridging this gap has been a top priority for our quality improvement program. To do so, we have used the TM&M classification and the TSQIC system as a foundation for several quality improvement initiatives. First, the divisional M&M conference has been greatly enhanced by the improved quality of statistical reporting of all surgical cases and all postoperative AEs for the preceding month, allowing the division to follow trends over time, and to distinguish between random variation and a significant increase or decrease in the rate of postoperative AEs.

    Second, using the TSQIC platform, we have developed novel and dynamic surgeon-specific adverse event reports (SAERs), allowing surgeons to compare their performance over time and to that of their colleagues through automated, real-time, and risk-adjusted data monitoring.

    A priority for the division has been to ensure such monitoring translates into tangible and reproducible improvements in surgical performance, for the benefit of surgeons, and ultimately patients. We have thus, implemented quarterly continuous quality improvement (CQI) seminars to provide an additional forum for discussion regarding collective results, utilizing the technique of positive deviance, to unmask best performers as a catalyst for discussing practice measures to improve specific AEs.

    Last, while not a primary objective, embracing a culture of quality has been an important outcome of our program. Because the process of TM&M data collection and analysis is integrated with monthly M&M conferences, SSAERs, and quarterly CQI seminars, it has been viewed as a multifaceted approach for creating a continuous culture of quality improvement that is supportive of teamwork, safety, and open and collegial dialogue regarding the links among structure, process, and outcomes of surgical care.
  • Collecting & Using Data



  • Terms
  • The Ottawa Thoracic Morbidity & Mortality (TM&M) Classification System was created to pursue surgical quality initiatives and we hope that utilization of this system in future studies can enable improvements in thoracic surgical quality.

    We do however suggest referencing this classification as the "Ottawa Thoracic Morbidity & Mortality (TM&M) Classification System".

    You are welcome to test out the TSQIC software at tsqic.org.
  • Presentations at International Conferences
  • Ivanovic J, Anstee C, Ramsay T, Gilbert S, Maziak DE, Shamji FM, Sundaresan RS, Villeneuve PJ, Seely, AJE. Development, implementation, and qualitative evaluation of surgeon-specific outcome reports and of a surgeon-led, continuous quality improvement program in thoracic surgery. 51st Society of Thoracic Surgeons Annual Meeting, January 2015. San Diego, California.

    Ivanovic J, Anstee C, Ramsay T, Villeneuve PJ, Gilbert S, Maziak DE, Shamji FM, Sundaresan RS, Seely AJE. Quality and patient safety in surgery: 5-year experience of the Thoracic Morbidity & Mortality Classification System. 19th International Forum for Quality and Safety in Healthcare, April 2014. Paris, France.

    Ivanovic J, Seely AJE, Anstee C, Villeneuve PJ, Gilbert S, Maziak DE, Shamji FM, Forster AJ, Sundaresan RS. Measuring surgical quality: A comparison of postoperative adverse events with the American College of Surgeons National Surgical Quality Improvement Program and the Thoracic Morbidity and Mortality System. 2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Conference, July 2013. San Diego, California.

    Ivanovic J, Ramsay T, Maziak DE, Gilbert S, Shamji FM, Sundaresan RS, and Seely AJE. Proposed Implementation and Evaluation of a Thoracic Surgery Quality Monitoring, Information Management, and Clinical Documentation System in a Cancer Assessment Clinic. 17thInternational Federation for Health Information Management (IFHIMA) Congress, May 2013. Montreal, Quebec.

    Seely AJE, Ivanovic J, Threader J, Al-Hussaini A, Al-Shehab D, Ramsay T, Maziak DE, Shamji FM, Sundaresan RS. Systematic Classification of Morbidity and Mortality following Thoracic Surgery. 46th Annual Meeting of the Society of Thoracic Surgeons, January 2010, Fort Lauderdale, Florida.
  • Presentations at National Conferences
  • Ivanovic J, Ramzan S, McGuire AL, Maziak DE, Gilbert S, Shamji FM, Sundaresan RS, Seely AJE. Quantifying the burden of atrial fibrillation following pulmonary resection using the Ottawa Thoracic Morbidity and Mortality classification system. 2013 Canadian Society of Epidemiology and Biostatistics Biennial Conference, June 2013. St. John’s, Newfoundland.
  • Presentations at Local Conferences
  • Ivanovic J, Anstee C, Finley C, Gilbert S, Maziak DE, Shamji FM, Sundaresan RS, Villeneuve PJ, Ramsay T, Seely AJE. Development and implementation of the Thoracic Surgery Quality Monitoring, Information Management, Clinical Documentation System for continuous, point-of-care reporting and evaluation of post-operative adverse events. Ottawa Hospital Research Institute (OHRI) Annual Research Conference, November 2014. Ottawa, Ontario.

    Ivanovic J, Anstee C, Ramsay T, Gilbert S, Maziak DE, Shamji FM, Sundaresan RS, Villeneuve PJ, Seely AJE. Development, implementation, and qualitative evaluation of surgeon-specific outcome reports and of a surgeon-led, continuous quality improvement program in thoracic surgery. 10th Annual Ottawa Hospital Patient Safety Conference, October 2014. Ottawa, Ontario.

    Ivanovic J, Seely AJE, Kwok ESH, Barlow-Krelina E, Frank JR, Cwinn A, Worthington J, Calder LA. Enhancing Thoracic Surgery M&M Rounds – Incorporating a Structured Model into a Standardized Adverse Event Classification System. 10th Annual Ottawa Hospital Patient Safety Conference, October 2014. Ottawa, Ontario.

    Ivanovic J, Seely AJE, Anstee C, Villeneuve PJ, Gilbert S, Maziak DE, Shamji FM, Forster AJ, Sundaresan RS. Measuring surgical quality: A comparison of postoperative adverse events with the American Colle ge of Surgeons National Surgical Quality Improvement Program and the Thoracic Morbidity and Mortality System. 9th Annual Ottawa Hospital Patient Safety Conference, October 2013. Ottawa, Ontario.

    Ivanovic J, Ramsay T, Maziak DE, Gilbert S, Shamji FM, Sundaresan RS, and Seely AJE. Improving patient care through the development and evaluation of the Thoracic Surgery Quality Monitoring, Information Management, and Clinical Documentation (TSQIC) System. 8th Annual Ottawa Hospital Patient Safety Conference, November 2012. Ottawa, Ontario.

    Ivanovic J, Khan Z, Anstee C, Ramsay T, Maziak DE, Gilbert S, Shamji FM, Sundaresan RS, and Seely AJE. Improving patient care through implementation of the Thoracic Surgery Quality Monitoring, Information Management, and Clinical Documentation (TSQIC) System. Ottawa Hospital Research Institute (OHRI) Annual Research Conference, November 2011. Ottawa, Ontario.