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Wound Classification Score Discordance in Pediatric Operations - A Quality Improvement Study
Roxane L Massoumi1, Joseph Wertz2, Noah Anderson3
1UCLA David Geffen School of Medicine, Department of General Surgery, Los Angeles, California.
Insights
A quality improvement program did not improve wound classification accuracy in an academic pediatric surgical setting. However, accuracy improved significantly at a community hospital, suggesting nursing education may need enhancement.
Area of Science:
- Surgical Quality Improvement
- Patient Safety
- Healthcare Informatics
Background:
- Inaccurate wound classification recording in electronic health records (EHRs) poses a risk for postoperative infections.
- A quality improvement initiative was implemented to address this charting inaccuracy at an academic institution.
Purpose of the Study:
- To evaluate the effectiveness of a quality improvement program in enhancing the accuracy of wound classification charting.
- To compare the impact of nursing-focused interventions versus physician-focused changes on charting accuracy.
Main Methods:
- A retrospective chart review compared pre- and post-intervention wound classification accuracy in pediatric operations.
- Data from an academic institution were compared with a nearby community hospital where the same surgeons practice.
- Pearson's Chi-squared test and Clopper-Pearson confidence intervals were used for statistical analysis.
Main Results:
- No significant improvement in charting accuracy was observed at the academic institution post-intervention.
- A significant improvement in appendectomy charting accuracy was noted at the community institution (3.33% to 44.83%).
Conclusions:
- The implemented quality improvement program did not significantly enhance wound classification accuracy at the academic institution.
- The observed improvement at the community hospital suggests potential deficiencies in nursing-focused interventions.
- Future efforts will concentrate on intensive and sustained operating room nurse training to improve accuracy.
Background:
Wound classification scores are used to categorize the risk of postoperative infections. It was noted at our academic institution that wound classifications were often inaccurately recorded in the electronic health record. We thus instituted a quality improvement program, hypothesizing that this would improve charting accuracy.
Methods:
On June 1, 2019, we posted the wound classifications in each pediatric operating room (OR), provided OR nurses with teaching, and began including the classification in the postoperative surgeon debriefing. We performed a retrospective chart review of all general pediatric operations from June 19 to December 19 to compare classifications recorded in the electronic health record to the "correct" classification determined by manual review of operating reports. These data were compared with a similar chart review from 2018. To compare the efficacy of nursing versus physician focused changes, we compared our appendectomy data with a nearby community institution where the same group of surgeons practice. Pearson's Chi-squared test was used to report the significance of the differences observed in the concordance proportion, with 95% confidence intervals calculated using the Clopper-Pearson procedure.
Results:
Overall, 444 pre- and 179 postpractice change charts were reviewed. There were no significant differences pre or postpractice change. At the community institution, we noted a significant improvement in charting accuracy for appendectomies from 3.33% to 44.83%.
Discussion:
Despite implementing nursing and physician focused quality improvement practices, there was not a significant improvement in charting accuracy at the academic institution. However, we did note an improvement at the community facility where our pediatric surgeons also practice. We thus suspect that our nursing focused changes may have been inadequate. Future efforts will focus on providing intensive and sustained OR nurse training to help improve the wound classification charting accuracy.
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