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A multicenter, pediatric quality improvement initiative improves surgical wound class assignment, but is it enough?
Luke R Putnam1, Shauna M Levy1, Martin L Blakely2
1Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA.
Insights
Quality improvement interventions significantly enhanced surgical wound classification (SWC) accuracy in pediatric hospitals. Despite improvements, ongoing inaccuracies in SWC highlight the need for careful evaluation in surgical site infection risk models.
Area of Science:
- Healthcare Quality Improvement
- Surgical Safety
- Pediatric Surgery
Background:
- Surgical wound classification (SWC) is crucial for assessing surgical site infection (SSI) risk and comparing hospital performance.
- Previous studies revealed significant inaccuracies in SWC for pediatric operations across multiple hospitals.
Purpose of the Study:
- To enhance multicenter, intraoperative SWC accuracy using targeted quality improvement (QI) interventions.
- To evaluate the effectiveness of QI strategies in improving SWC assignment.
Main Methods:
- A before-and-after study design was implemented across eleven children's hospitals from 2011 to 2014.
- Intraoperative SWC records were compared against surgeon-assigned SWC using a standardized algorithm.
- Agreement metrics, including Cohen's weighted kappa and chi-square, were used to analyze changes.
Main Results:
- Overall SWC agreement improved substantially from 56% to 76% (p<0.01) between 2011 and 2013.
- Weighted kappa increased from 0.45 to 0.73, indicating a significant improvement in agreement.
- A dose-response relationship was observed between the number of QI interventions and the degree of SWC agreement improvement.
Conclusions:
- Multifaceted, resource-intensive QI interventions led to significant improvements in intraoperative SWC assignment.
- Despite improvements, inaccuracies in SWC persist, necessitating careful consideration when used for SSI risk stratification and hospital comparisons.
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.
