Quality Check of a Quality Measure: Surgical Wound Classification Discrepancies Impact Risk-Stratified Surgical Site Infection Rates in Pediatric Appendicitis

Abstract

BACKGROUND: 

The impact of quality measures in health care and reimbursement is growing. Ensuring the accuracy of quality measures, including any risk-stratification variables, is necessary. Surgical site infection rates, risk stratified by surgical wound classification (SWC) among other variables, are increasingly considered as quality measures. We hypothesized that hospital-documented and diagnosis-based SWCs are frequently discordant and that diagnosis-based SWCs better predict surgical site infection rates.

STUDY DESIGN: 

All pediatric patients (ie, younger than 18 years old) at a single institution who underwent an appendectomy for appendicitis between October 1, 2010 and August 31, 2011 were included. Each chart was reviewed to determine the hospital-documented SWC, which is recorded by the circulating nurse (options included clean, clean-contaminated, contaminated, and dirty); SWC based on the surgeons' postoperative diagnosis, including contaminated (ie, acute nonperforated, nongangrenous appendicitis), dirty (ie, gangrenous and perforated appendicitis), and 30-day postoperative surgical site infections.

RESULTS: 

Of the 312 evaluated appendicitis cases, the diagnosis-based and circulating nurse–based SWCs differed in 288 (92%) cases. The circulating nurse–based and diagnosis-based SWCs differed by more than one SWC in 176 (56%) cases. Surgical site infections were associated with worsening diagnosis-based SWC, but not with circulating nurse–based SWC.

CONCLUSIONS: 

Significant discordance exists between hospital documentation by the circulating nurse- and surgeon diagnosis-based SWCs. Inconsistency in risk-stratified quality measures can have a significant effect on outcomes measures, which can lead to misdirection of quality-improvement efforts, incorrect inter-hospital rating, reduced reimbursements, and public misperceptions about quality of care.

In Brief

Surgical wound classification is an important component of surgical site infection risk stratification. The wound class that is determined by the circulating nurse is frequently discordant with diagnosisbased surgical wound class for appendicitis cases at our institution. This leads to variability in risk stratification.