Operating room staff and surgeon documentation curriculum improves wound classification accuracy

Area of Science:

• Surgical safety and quality improvement
• Healthcare documentation best practices
• Operating room (OR) protocols

Background:

• Inaccurate surgical wound classification (SWC) in the operating room (OR) impacts surgical site infection (SSI) reporting and reimbursement.
• Standardized SWC is crucial for accurate patient risk assessment and quality metrics.

Purpose of the Study:

• To evaluate the effectiveness of a multidisciplinary curriculum on improving SWC documentation accuracy among OR staff and surgeons.
• To reduce errors in SWC to enhance the reliability of SSI risk assessment.

Main Methods:

• A retrospective chart review assessed SWC accuracy before and after a 9-month intervention involving two plan-do-act-study (PDSA) cycles.
• SWC documentation was compared between initial OR records and in-depth chart reviews for 747 inpatient procedures.
• Changes in documentation accuracy were analyzed using the kappa coefficient to measure agreement.

Main Results:

• The curriculum implementation led to a significant improvement in SWC documentation accuracy, with kappa values increasing from 0.553 to 0.739 and 0.757 (p = 0.001).
• Classification accuracy improved for all wound classes, though Class III and IV wounds remained more prone to misclassification than Class I and II wounds.

Conclusions:

• A multidisciplinary documentation curriculum effectively reduced SWC errors in the OR.
• Enhanced SWC accuracy supports more reliable assessment of SSI risk, particularly in complex patient populations.