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J Pediatr Surg. 2016 Apr;51(4):639-44. doi: 10.1016/j.jpedsurg.2015.10.046. Epub 2015 Oct 20.

A multicenter, pediatric quality improvement initiative improves surgical wound class assignment, but is it enough?

Author information

1
Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA.
2
Vanderbilt Children's Hospital, Vanderbilt University Medical Center, Nashville, TN, USA.
3
Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
4
Children's of Alabama, University of Alabama Birmingham School of Medicine, Birmingham, AL, USA.
5
Le Bonheur Children's Hospital, The University of Tennessee Health Science Center, Memphis, TN, USA.
6
St. Louis Children's Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
7
MUSC Children's Hospital, Medical University of South Carolina, Charleston, SC, USA.
8
Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA; Children's Hospital Los Angeles, Keck Medical Center of USC, Los Angeles, CA, USA.
9
Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA.
10
Children's Mercy Hospital, University of Missouri - Kansas City School of Medicine, Kansas City, MO, USA.
11
Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
12
Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA. Electronic address: kuojen.tsao@uth.tmc.edu.

Abstract

BACKGROUND/PURPOSE:

Surgical wound classification (SWC) is widely utilized for surgical site infection (SSI) risk stratification and hospital comparisons. We previously demonstrated that nearly half of common pediatric operations are incorrectly classified in eleven hospitals. We aimed to improve multicenter, intraoperative SWC assignment through targeted quality improvement (QI) interventions.

METHODS:

A before-and-after study from 2011-2014 at eleven children's hospitals was conducted. The SWC recorded in the hospital's intraoperative record (hospital-based SWC) was compared to the SWC assigned by a surgeon reviewer utilizing a standardized algorithm. Study centers independently performed QI interventions. Agreement between the hospital-based and surgeon SWC was analyzed with Cohen's weighted kappa and chi square.

RESULTS:

Surgeons reviewed 2034 cases from 2011 (Period 1) and 1998 cases from 2013 (Period 2). Overall SWC agreement improved from 56% to 76% (p<0.01) and weighted kappa from 0.45 (95% CI 0.42-0.48) to 0.73 (95% CI 0.70-0.75). Median (range) improvement per institution was 23% (7-35%). A dose-response-like pattern was found between the number of interventions implemented and the amount of improvement in SWC agreement at each institution.

CONCLUSIONS:

Intraoperative SWC assignment significantly improved after resource-intensive, multifaceted interventions. However, inaccurate wound classification still commonly occurred. SWC used in SSI risk-stratification models for hospital comparisons should be carefully evaluated.

KEYWORDS:

quality metric; risk stratification; surgical site infection; surgical wound class; wound classification

PMID:
26590473
DOI:
10.1016/j.jpedsurg.2015.10.046
[Indexed for MEDLINE]

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