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J Am Coll Surg. 2015 Mar;220(3):323-9. doi: 10.1016/j.jamcollsurg.2014.11.007. Epub 2014 Nov 20.

Surgical wound misclassification: a multicenter evaluation.

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Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX.
Vanderbilt Children's Hospital, Vanderbilt University Medical Center, Nashville, TN.
Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI.
Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR.
Le Bonheur Children's Hospital, The University of Tennessee Health Science Center, Memphis, TN.
Children's Hospital Los Angeles, Keck Medical Center of USC, Los Angeles, CA.
Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
Children's of Alabama, University of Alabama Birmingham School of Medicine, Birmingham, AL.
Children's Mercy Hospital, University of Missouri, Kansas City School of Medicine, Kansas City, MO.
MUSC Children's Hospital, Medical University of South Carolina, Charleston, SC.
St Louis Children's Hospital, Washington University in St Louis School of Medicine, St Louis, MO.
Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX. Electronic address:



Surgical wound classification (SWC) is used by hospitals, quality collaboratives, and Centers for Medicare and Medicaid to stratify patients for their risk for surgical site infection. Although these data can be used to compare centers, the validity and reliability of SWC as currently practiced has not been well studied. Our objective was to assess the reliability of SWC in a multicenter fashion. We hypothesized that the concordance rates between SWC in the electronic medical record and SWC determined from the operative note review is low and varies by institution and operation.


Surgical wound classification concordance was assessed at 11 participating institutions between SWC from the electronic medical record and SWC from operative note review for 8 common pediatric surgical operations. Cases with concurrent procedures were excluded. A maximum of 25 consecutive cases were selected per operation from each institution. A designated surgeon reviewed the included operative notes from his/her own institution to determine SWC based on a predetermined algorithm.


In all, 2,034 cases were reviewed. Overall SWC concordance was 56%, ranging from 47% to 66% across institutions. Inguinal hernia repair had the highest overall median concordance (92%) and appendectomy had the lowest (12%). Electronic medical records and reviewer SWC differed by up to 3 classes for certain cases.


Surgical site infection risk stratification by SWC, as currently practiced, is an unreliable methodology to compare patients and institutions. Surgical wound classification should not be used for quality benchmarking. If SWC continues to be used, individual institutions should evaluate their process of assigning SWC to ensure its accuracy and reliability.

[Indexed for MEDLINE]

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