Division of Pediatric Surgery, Department of Surgery, University Of Wisconsin School of Medicine and Public Health
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1 Surgeon-Directed Surgical Wound Classification During a Structured Operative Debrief Improves Accuracy of Wound Classification for Common Pediatric Surgery Procedures University Of Wisconsin Hospital And Clinics, American Family Children s Hospital Tiffany J. Zens, MD 1,3, Charles M. Leys, MD 1,3, Deborah A. Rusy, MD 2,3, Ankush Gosain, MD, PhD 1,3 1 Division of Pediatric Surgery, Department of Surgery, University Of Wisconsin School of Medicine and Public Health 2 Division of Pediatric Anesthesia, Department of Anesthesia, University Of Wisconsin School of Medicine and Public Health 3 University of Wisconsin Hospital And Clinics, American Family Children s Hospital, Madison, WI, USA
2 BACKGROUND- SURGICAL WOUND CLASSIFICATION - Universal system established in Four categories: -,,, Dirty/Infected - Commonly recorded in the electronic medical record by circulating nurses, surgical residents or attending surgeons - Communicates the degree of bacterial contamination in the operative field - Used by researchers, hospitals, quality improvement committees and third party payers for risk stratification
3 WOUND CLASSIFICATION AND OUTCOMES - Rates of surgical site infections 1 - : 1-5% - : 3-11% - : 10-17% - Dirty/Infected: 27% - Accuracy of Wound Classifications - 92% of appendectomies incorrectly identified 2 - Multicenter evaluation of 2,034 cases in 11 institutions: concordance rate across institutions 47-66% 3 - Study of over 200 neonatal surgeries show poor reliability of wound class 4
4 OUR STUDY - Hypothesis: - Changing from a nurse-directed wound classification to surgeon-directed classification will improve accuracy - Intervention: - Formal debriefing at the completion of each operative case to review: - Correct antibiotics and re-dosing - Surgeon concerns - Anesthesia concerns - Patient disposition - Surgical wound class - Surgical wound class was recorded by surgical resident
5 STUDY DESIGN - Retrospective chart review from June 2012 to August One common pediatric surgical procedure was chosen to represent each wound class - : Inguinal hernia repair - : Gastrostomy tube placement +/- Nissen - : Appendectomy, non-perforated - Dirty/Infected: Appendectomy, perforated - All operative reports were reviewed to determine if unexpected intraoperative finding or event would change wound class - Outcomes: - Primary: - Accuracy of wound classification documentation - Secondary: - Degree of error in wound classification - Surgical Complications
6 STUDY DESIGN Total Cases (457 cases) Cases Excluded from Study (132 cases) Cases Included in Study (325 cases) No documented wound class (14 cases) No documented debriefing after implementation (112 cases) Complex case outside scope of study (6 cases) Pre-Debriefing (183 cases) Post- Debriefing (142 cases) Dirty/Infected Dirty/Infected
7 RESULTS: ACCURACY OF WOUND CLASSIFICATION - Percentage of correctly identified wound classes increased from 42% to 58.5% - Improvement in accuracy seen across all wound classes Percentage of Correctly Identified Wound Class 100.0% 90.0% 94.4% 89.8% 86.9% Cases Correctly Identified 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 53.3% 8.3% 3.3% 18.5% 60.0% Pre Debriefing Post Debriefing 0.0% Dirty/Infected Wound Class
8 RESULTS: DEGREE OF ERROR - Percentage of cases over or underestimated by more than one wound class decreased from 26.8% to 3.5% Percentage of Cases 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Degree of Overestimation or Underestimation of Wound Class in All Cases Correct Pre-Debrief Post-Debrief Overestimation (+) or Underestimation (-) of Wound Class - Improvement in accuracy seen across all wound classes
9 DEGREE OF ERROR: CLEAN CASES Cases Pre-Debrief Post-Debrief % 90.00% 80.00% 89.80% 94.40% Percentage of Cases 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 10.20% 5.60% 0% 0% 0% 0% Dirty or Infected
10 DEGREE OF ERROR: CLEAN CONTAMINATED CASES Pre-Debrief Post-Debrief % 90.00% 86.80% 80.00% Percentage of Cases 70.00% 60.00% 50.00% 40.00% 30.00% 40.40% 53.20% 20.00% 10.00% 0.00% 10.50% 6.40% 2.60% 0% 0% Dirty or Infected
11 DEGREE OF ERROR: CONTAMINATED CASES Cases Pre-Debrief Post-Debrief 100% 90% 80% 83.30% Percentage of Cases 70% 60% 50% 40% 30% 55% 41.70% 20% 10% 0% 6.30% 3.30% 8.30% 0% 2.10% Dirty or Infected
12 DEGREE OF ERROR: DIRTY/INFECTED CASES Dirty/Infected Cases Pre-Debrief Post-Debrief % 90.00% 80.00% Percentage of Cases 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 33.30% 0% 25.90% 10% 22.20% 30% 18.50% 60% Dirty or Infected
13 RESULTS: SURGICAL COMPLICATIONS - Statistically significant differences in rates of SSI, readmissions and complications across all wound classes - + dirty/infected cases accounted for approximately 2/3 (64.3%) of all readmissions in our study - Dirty/infected cases accounted for 60% of all complications in our study Complication n= 85 n= 85 n= 108 Dirty/Infected n= 47 Chi Squared P value Surgical Site Infection 0 (0%) 5 (6%) 0 (0%) 1 (2%) Readmission 1 (1%) 4 (5%) 2 (2%) 7 (15%) All Complications 1 (1%) 8 (9%) 3 (3%) 18 (38%)
14 CONCLUSIONS - A surgeon directed wound classification system improves accuracy of documentation and decreases degree of error of incorrectly identified cases. - Further interventions are needed to improve the accuracy of wound classification documentation in the pediatric population. - There is still significant room for improvement. Our postintervention incorrect wound classification rate: 41.5%.
15 THE NEXT STEP - Continue to improve accuracy of documentation through: - Read-back and real time documentation in the OR - Focused educational model course for residents - Further research opportunities: - Assess baseline knowledge of correct wound classifications for different groups: attendings, residents, circulating nurses - Assess improvement with focused education course
16 REFERENCES 1) Ortega, G, Rhee DS, Papandria DJ, Yang J, Ibrahim AM, Shore AD, Makary MA, Abdullah F. An Evaluation of Surgical Site Infections by Wound Classification System Using the ACS-NSQIP. Journal of Surgical Research June; 175(1): ) Levy SM, Holzmann-Pazgal G, Lally KP, Davis K, Kao LS, Tsao K, Levy Sm. Quality check of a quality measure: surgical wound classification discrepancies impact risk-stratified surgical site infection rates in pediatric appendicitis. J Am Coll Surg Dec;217(6): ) Levy SM, Lally KP, Blakely ML, Calkins CM, Dassinger MS, Duggan E, Huang EY, Kawaguchi AL, Lopez ME, Russell RT, St Peter SD, Streck CJ, Vogel AM, Tsao K. Surgical wound misclassification: a multicenterevaluation Surgical wound misclassification: a multicenter evaluation. Pediatric Surgery Research Collaborative. J Am Coll Surg Mar;220(3): ) Vu KK, Nobuhara LT, LH, Farmer DL. Conflicts in wound classification of neonatal operations J Pediatr Surg, 2009;44:
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