Implementation of the World Health Organization checklist and debriefing improves accuracy of surgical wound class documentation

An analysis of 3,954 cases to determine surgical wound classification accuracy: Does your institution need a monday morning quarterback?

INTRODUCTION

Surgical site infections reporting has financial implications for institutions under Centers for Medicare and Medicaid Services (CMS) Pay-for-Performance programs. Surgical Wound Classification (SWC) is an important factor in performing risk adjustment and affects the accuracy of the Standardized Infection Ratio (SIR). This in turn leads to more accurate inter-hospital ratings and reimbursement. This study aims to measure (1) services and procedures associated with the highest rates of misclassification and (2) whether temporal factors influenced misclassification.

METHODS

Accuracy of SWC was assessed by comparing the wound classification documented by the Operating Room (OR) nurse at the time of the operation to the actual SWC determined from in-depth chart review using Centers for Disease Control and Prevention (CDC) wound classification algorithm by a trained reviewer. Cases were reviewed once operative reports were available.

RESULTS

Review of 3954 cases yielded an overall discordance rate of 22.15% (N = 876), with most cases being under-classified. Services with the highest rates of discordance include cardiothoracic (38.46%) and general surgery (37.86%), followed by general oncology (29.46%), OB-GYN (28.93%), urology (27.27%), and plastic surgery (27.14%). Procedures with the highest discordance rates are laparoscopic appendectomy (66.67%), cholecystectomy (52.90%), exploratory laparotomy (49.21%), and split-thickness skin graft (36.84%). Discordance rates were significantly higher (p = 0.0001) during weekends compared to weekdays, while operations starting after-hours during the week did not show a significant difference from daytime hours.

CONCLUSION

At a level 1 trauma academic medical center, certain procedures were found to be misclassified in regards to SWC more often than other types of cases. The timing of the case, such that they occurred on the weekends also contributed to higher discordance rates between original and corrected wound classifications. Recognizing cases, services, and temporal factors frequently associated with misclassification of wound class can help allocate limited resources to maximize improvement of this important metric.

Surgical Safety Checklists in Children's Surgery: Surgeons' Attitudes and Review of the Literature

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Introduction:

Surgical safety checklists (SSCs) aim to create a safe operating room environment for surgical patients. Provider attitudes toward checklists affect their ability to prevent harm. Pediatric surgeons’ perceptions surrounding SSCs, and their role in improving patient safety, are unknown.

Methods:

American Pediatric Surgical Association members conducted an online survey to evaluate the use of and attitudes toward SSCs. The survey measured surgeons’ perceptions of checklists, including the components that make them effective and barriers to participation. To better evaluate the available data on SSCs, the authors performed a systematic literature review on the use of SSCs with a focus on pediatric studies.

Results:

Of the 353 survey respondents, 93.6% use SSCs and 62.6% would want one used in their own child’s operation, but only 54.7% felt that checklists improve patient safety. Reasons for checklist skepticism included the length of the checklist process, a distraction from thoughtful patient care, and lack of data supporting use. Literature review shows that checklists improve communication, promote teamwork, and identify errors, but do not necessarily decrease morbidity. Staff perception is a major barrier to implementation.

Conclusions:

Almost all pediatric surgeons participate in SSCs at their institutions, but many question their benefit. Better pediatric surgeon engagement in checklist use is needed to change the safety culture, improve operating room communication, and prevent harm.

Operating room staff and surgeon documentation curriculum improves wound classification accuracy

BACKGROUND

Misclassification of wounds in the operating room (OR) can adversely affect surgical site infection (SSI) reporting and reimbursement. This study aimed to measure the effects of a curriculum on documentation of surgical wound classification (SWC) for operating room staff and surgeons.

METHODS

Accuracy of SWC was determined by comparing SWC documented by OR staff during the original operation to SWC determined by in-depth chart review. Patients 18 years or older undergoing inpatient surgical procedures were included. Two plan-do-act-study (PDSA) cycles were implemented over the course of 9 months. A total of 747 charts were reviewed. Accuracy of SWC documentation was retrospectively assessed across 248 randomly selected surgeries during a 5-week period prior to interventions and compared to 244 cases and 255 cases of post-intervention data from PDSA1 and PDSA2, respectively. Changes in SWC accuracy were assessed pre- and post-intervention using the kappa coefficient. A p-value for change in agreement was computed by comparing pre- and post-intervention kappa.

RESULTS

Inaccurate documentation of surgical wound class decreased significantly following curriculum implementation (kappa improved from 0.553 to 0.739 and 0.757; p = 0.001). Classification accuracy improved across all wound classes; however, class III and IV wounds were more frequently misclassified than class I and II wounds, both before and after the intervention.

CONCLUSION

Implementation of a multidisciplinary documentation curriculum resulted in a significant decrease in SWC documentation error. Improved accuracy of SWC reporting may facilitate a better assessment of SSI risk in a complex patient population.

Advances in perioperative quality and safety

For decades, safe surgery focused on intraoperative technique and decision-making. The traditional hierarchy placed the surgeon as the leader with ultimate authority and responsibility. Despite the advances in surgical technique and equipment, too many patients have suffered unnecessary complications and suboptimal care. Today, we understand that the conduct of safe and effective surgery requires evidence-based decision-making, multifaceted treatment approaches to prevent complications, and effective communication in and out of the operating room. In this manuscript, we describe three significant advances in quality and safety that have changed the approach to surgical care: the National Surgical Quality Improvement Program, evidence-based bundled prevention of surgical site infections, and the Surgical Safety Checklist.

Effectiveness and meaningful use of paediatric surgical safety checklists and their implementation strategies: a systematic review with narrative synthesis

OBJECTIVE

To examine the effectiveness and meaningful use of paediatric surgical safety checklists (SSCs) and their implementation strategies through a systematic review with narrative synthesis.

SUMMARY BACKGROUND DATA

Since the launch of the WHO SSC, checklists have been integrated into surgical systems worldwide. Information is sparse on how SSCs have been integrated into the paediatric surgical environment.

METHODS

A broad search strategy was created using Pubmed, Embase, CINAHL, Cochrane Central, Web of Science, Science Citation Index and Conference Proceedings Citation Index. Abstracts and full texts were screened independently, in duplicate for inclusion. Extracted study characteristic and outcomes generated themes explored through subgroup analyses and idea webbing.

RESULTS

1826 of 1921 studies were excluded after title and abstract review (kappa 0.77) and 47 after full-text review (kappa 0.86). 20 studies were of sufficient quality for narrative synthesis. Clinical outcomes were not affected by SSC introduction in studies without implementation strategies. A comprehensive SSC implementation strategy in developing countries demonstrated improved outcomes in high-risk surgeries. Narrative synthesis suggests that meaningful compliance is inconsistently measured and rarely achieved. Strategies involving feedback improved compliance. Stakeholder-developed implementation strategies, including team-based education, achieved greater acceptance. Three studies suggest that parental involvement in the SSC is valued by parents, nurses and physicians and may improve patient safety.

CONCLUSIONS

A SSC implementation strategy focused on paediatric patients and their families can achieve high acceptability and good compliance. SSCs' role in improving measures of paediatric surgical outcome is not well established, but they may be effective when used within a comprehensive implementation strategy especially for high-risk patients in low-resource settings.