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Bernstein JD, Bracken DJ, Abeles SR, Orosco RK, Weissbrod PA. Surgical wound classification in otolaryngology: A state‐of‐the‐art review. World J Otorhinolaryngol Head Neck Surg 2022; 8:139-144. [PMID: 35782398 PMCID: PMC9242420 DOI: 10.1002/wjo2.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 12/05/2021] [Indexed: 12/04/2022] Open
Abstract
Objective To describe the issues related to the assignment of surgical wound classification as it pertains to Otolaryngology—Head & Neck surgery, and to present a simple framework by which providers can assign wound classification. Data Sources Literature review. Conclusion Surgical wound classification in its current state is limited in its utility. It has recently been disregarded by major risk assessment models, likely due to inaccurate and inconsistent reporting by providers and operative staff. However, if data accuracy is improved, this metric may be useful to inform the risk of surgical site infection. In an era of quality‐driven care and reimbursement, surgical wound classification may become an equally important indicator of quality. In its current state, surgical wound classification has been disregarded as a key metric, likely due to habitual inaccuracies in procedure categorization. A new paradigm for surgical wound classification specific to Otolaryngology—Head & Neck Surgery is presented. The possibility of surgical wound classification serving as an important indicator of quality of care is discussed and contextualized in current health care trends.
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Affiliation(s)
- Jeffrey D. Bernstein
- Department of Otolaryngology University of California San Diego La Jolla California USA
| | - David J. Bracken
- Department of Otolaryngology University of California San Diego La Jolla California USA
| | - Shira R. Abeles
- Department of Medicine, Division of Infectious Disease and Global Public Health University of California San Diego San Diego California USA
| | - Ryan K. Orosco
- Department of Otolaryngology University of California San Diego La Jolla California USA
- Moores Cancer Center University of California San Diego La Jolla California USA
| | - Philip A. Weissbrod
- Department of Otolaryngology University of California San Diego La Jolla California USA
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Massoumi RL, Wertz J, Anderson N, Barrett N, Jen HC. Wound Classification Score Discordance in Pediatric Operations - A Quality Improvement Study. J Surg Res 2021; 268:681-686. [PMID: 34482008 DOI: 10.1016/j.jss.2021.06.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 05/04/2021] [Accepted: 06/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Wound classification scores are used to categorize the risk of postoperative infections. It was noted at our academic institution that wound classifications were often inaccurately recorded in the electronic health record. We thus instituted a quality improvement program, hypothesizing that this would improve charting accuracy. METHODS On June 1, 2019, we posted the wound classifications in each pediatric operating room (OR), provided OR nurses with teaching, and began including the classification in the postoperative surgeon debriefing. We performed a retrospective chart review of all general pediatric operations from June 19 to December 19 to compare classifications recorded in the electronic health record to the "correct" classification determined by manual review of operating reports. These data were compared with a similar chart review from 2018. To compare the efficacy of nursing versus physician focused changes, we compared our appendectomy data with a nearby community institution where the same group of surgeons practice. Pearson's Chi-squared test was used to report the significance of the differences observed in the concordance proportion, with 95% confidence intervals calculated using the Clopper-Pearson procedure. RESULTS Overall, 444 pre- and 179 postpractice change charts were reviewed. There were no significant differences pre or postpractice change. At the community institution, we noted a significant improvement in charting accuracy for appendectomies from 3.33% to 44.83%. DISCUSSION Despite implementing nursing and physician focused quality improvement practices, there was not a significant improvement in charting accuracy at the academic institution. However, we did note an improvement at the community facility where our pediatric surgeons also practice. We thus suspect that our nursing focused changes may have been inadequate. Future efforts will focus on providing intensive and sustained OR nurse training to help improve the wound classification charting accuracy.
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Affiliation(s)
- Roxane L Massoumi
- UCLA David Geffen School of Medicine, Department of General Surgery, Los Angeles, California
| | - Joseph Wertz
- UCLA David Geffen School of Medicine, Los Angeles, California
| | | | | | - Howard C Jen
- Mattel Children's Hospital at UCLA, Division of Pediatric Surgery, Los Angeles, California.
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Stefanou A, Worden A, Kandagatla P, Reickert C, Rubinfeld I. Surgical Wound Misclassification to Clean From Clean-Contaminated in Common Abdominal Operations. J Surg Res 2019; 246:131-138. [PMID: 31580983 DOI: 10.1016/j.jss.2019.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 07/28/2019] [Accepted: 09/03/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Wound classification helps predict wound-related complications and is useful in stratifying surgical site infection reporting. We sought to evaluate misclassification among commonly performed surgeries that are at least clean-contaminated. MATERIALS AND METHODS The National Surgical Quality Improvement Program database was queried from 2005 to 2016 by Current Procedural Terminology codes identifying common surgeries that are, by definition, not clean: colectomy, cholecystectomy, hysterectomy, and appendectomy. Univariate analysis and multivariate logistic regression were performed. RESULTS Of the 1,208,544 operative cases reviewed, 22,925 (1.90%) were misclassified as clean. Hysterectomy was the most commonly misclassified operation (3.11%), and colectomy the least (0.82%). Misclassification was higher in laparoscopic cases (1.92% versus 1.82%; P < 0.01). Misclassification increased from 2005 to 2016 (0.22% versus 3.11%; P < 0.01). Misclassified patients were younger (46.7 versus 47.7 y; P < 0.01); had lower rates of hypertension, chronic obstructive pulmonary disease, smoking history, and steroid use (P < 0.01); and had shorter length of stay (2.2 versus 3.2 d; P < 0.01), lower 30-d readmission rates (3.7% versus 5.0%; P < 0.01), and less surgical site infections (1.7% versus 3.4%; P < 0.01). Open hysterectomy was the most significant positive predictor for misclassification (odds ratio 3.34; P < 0.01). Open appendectomy was the most significant negative predictor (odds ratio 0.20; P < 0.01). CONCLUSIONS There is an increasing trend of misclassifying wounds as clean. Misclassified patients have better outcomes, and misclassification may be affected by patient characteristics, operative approach, and type of procedure rather than reflecting the true infectious burden. Further research is warranted.
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Affiliation(s)
- Amalia Stefanou
- Department of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan.
| | - Andrew Worden
- Department of General Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Pridvi Kandagatla
- Department of General Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Craig Reickert
- Department of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Ilan Rubinfeld
- Department of General Surgery, Henry Ford Hospital, Detroit, Michigan
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Butler MW, Zarosinski S, Rockstroh D. Improvement of surgical wound classification following a targeted training program at a children's hospital. J Pediatr Surg 2018; 53:2378-2382. [PMID: 30268490 DOI: 10.1016/j.jpedsurg.2018.08.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 08/25/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Inaccurate assignment of surgical wound class (SWC) remains a challenge in perioperative documentation. The purpose of our intervention was to increase the accuracy of SWC through a targeted training program directed toward pediatric surgeons and nurses. METHODS A retrospective electronic medical record (EMR) chart review of 400 operations was performed according to NSQIP criteria during specified periods in 2014 and 2017, assessing SWC errors before and after a training program and posting of reference materials in operating rooms at a 165-bed children's hospital. After each operation, nurses confirmed SWC with the surgeon before recording the value in the EMR. Differences in proportions of misclassified SWC were evaluated with a chi-square test. RESULTS Following the educational program, misclassified SWC improved from 70/200 (35.0%) to 18/200 (9.0%), p < 0.001. Misclassified SWC for appendectomies improved from 46/95 (48.4%) to 12/108 (11.1%), p < 0.001. CONCLUSIONS Accurate SWC assignment in the EMR was improved by an educational program and posting of materials to aid assignment, as well as enhanced communication between surgeons and nurses at the conclusion of each operation. We present the first known attempt to list all pediatric surgery procedures according to SWC. Accurate SWC allows stratification of risks and more effective targeted interventions. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Marilyn W Butler
- Pediatric National Surgical Quality Improvement Program, Randall Children's Hospital, 2801 N Gantenbein Avenue, Portland, OR, 97227, USA; Oregon Health and Science University, Portland, OR, USA.
| | - Sandy Zarosinski
- Pediatric National Surgical Quality Improvement Program, Randall Children's Hospital, 2801 N Gantenbein Avenue, Portland, OR, 97227, USA.
| | - Dagmar Rockstroh
- Pediatric National Surgical Quality Improvement Program, Providence St. Vincent Medical Center, 9205 SW Barnes Road, Portland, OR, 97225, USA.
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Berman L, Raval MV, Goldin A. Process improvement strategies: Designing and implementing quality improvement research. Semin Pediatr Surg 2018; 27:379-385. [PMID: 30473043 DOI: 10.1053/j.sempedsurg.2018.10.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Quality improvement (QI) is the practice of continuously evaluating and improving the quality of health care that is delivered to patients. In this article, we will use practical examples to show how quality improvement projects have improved surgical patient care, and can be shared between institutions to accelerate the pace of improvement. We will explain the differences between quality improvement and research, and describe the methodological approach to performing and reporting quality improvement projects. Finally, we will describe ways to disseminate and widely implement changes in clinical practice using QI methodology. Even if they are not initiating and developing QI projects, all surgeons are likely to be affected by improvement initiatives going on in their hospitals, and should understand their valuable contribution to patient care.
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Affiliation(s)
- Loren Berman
- Division of Pediatric Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, PA and Nemours-AI DuPont Hospital for Children, Wilmington, DE, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Adam Goldin
- University of Washington School of Medicine, Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, OFFICE 4800 Sand Point Way NE, Seattle, WA 98105. MAIL M/S W-7729, PO Box 5371, Seattle, WA, 98105, USA.
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Gorvetzian JW, Epler KE, Schrader S, Romero JM, Schrader R, Greenbaum A, McKee R. Operating room staff and surgeon documentation curriculum improves wound classification accuracy. Heliyon 2018; 4:e00728. [PMID: 30109278 PMCID: PMC6088459 DOI: 10.1016/j.heliyon.2018.e00728] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 06/08/2018] [Accepted: 08/03/2018] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Samuel Schrader
- University of New Mexico, School of Medicine, Albuquerque, NM, USA
| | - Joshua M. Romero
- University of New Mexico, School of Medicine, Albuquerque, NM, USA
| | | | - Alissa Greenbaum
- University of New Mexico, Department of Surgery, Albuquerque, NM, USA
| | - Rohini McKee
- University of New Mexico, Department of Surgery, Albuquerque, NM, USA
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Abstract
BACKGROUND Surgical site infections (SSIs) are a significant healthcare quality issue, resulting in increased morbidity, disability, length of stay, resource utilization, and costs. Identification of high-risk patients may improve pre-operative counseling, inform resource utilization, and allow modifications in peri-operative management to optimize outcomes. METHODS Review of the pertinent English-language literature. RESULTS High-risk surgical patients may be identified on the basis of individual risk factors or combinations of factors. In particular, statistical models and risk calculators may be useful in predicting infectious risks, both in general and for SSIs. These models differ in the number of variables; inclusion of pre-operative, intra-operative, or post-operative variables; ease of calculation; and specificity for particular procedures. Furthermore, the models differ in their accuracy in stratifying risk. Biomarkers may be a promising way to identify patients at high risk of infectious complications. CONCLUSIONS Although multiple strategies exist for identifying surgical patients at high risk for SSIs, no one strategy is superior for all patients. Further efforts are necessary to determine if risk stratification in combination with risk modification can reduce SSIs in these patient populations.
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Affiliation(s)
- Krislynn M Mueck
- Department of Surgery, University of Texas Health Science Center at Houston , Houston, Texas
| | - Lillian S Kao
- Department of Surgery, University of Texas Health Science Center at Houston , Houston, Texas
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Utilization of the NSQIP-Pediatric Database in Development and Validation of a New Predictive Model of Pediatric Postoperative Wound Complications. J Am Coll Surg 2017; 224:532-544. [PMID: 28069525 DOI: 10.1016/j.jamcollsurg.2016.12.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 12/19/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Surgical wound classification, introduced in 1964, stratifies the risk of surgical site infection (SSI) based on a clinical estimate of the inoculum of bacteria encountered during the procedure. Recent literature has questioned the accuracy of predicting SSI risk based on wound classification. We hypothesized that a more specific model founded on specific patient and perioperative factors would more accurately predict the risk of SSI. STUDY DESIGN Using all observations from the 2012 to 2014 pediatric National Surgical Quality Improvement Program-Pediatric (NSQIP-P) Participant Use File, patients were randomized into model creation and model validation datasets. Potential perioperative predictive factors were assessed with univariate analysis for each of 4 outcomes: wound dehiscence, superficial wound infection, deep wound infection, and organ space infection. A multiple logistic regression model with a step-wise backwards elimination was performed. A receiver operating characteristic curve with c-statistic was generated to assess the model discrimination for each outcome. RESULTS A total of 183,233 patients were included. All perioperative NSQIP factors were evaluated for clinical pertinence. Of the original 43 perioperative predictive factors selected, 6 to 9 predictors for each outcome were significantly associated with postoperative SSI. The predictive accuracy level of our model compared favorably with the traditional wound classification in each outcome of interest. CONCLUSIONS The proposed model from NSQIP-P demonstrated a significantly improved predictive ability for postoperative SSIs than the current wound classification system. This model will allow providers to more effectively counsel families and patients of these risks, and more accurately reflect true risks for individual surgical patients to hospitals and payers.
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