Wound Classification in Pediatric General Surgery: Significant Variation Exists among Providers

Snyder, Rebecca A.; Johnson, L. F.; Tice, Jamie; Wingo, Tammy L; Williams, Dana I.; Wang, Li; Blakely, Martin L.

doi:10.1016/j.jamcollsurg.2013.05.027

Cited by 20 publications

(17 citation statements)

References 18 publications

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“…Conversely, NSQIP reviewers who are specifically trained on the SWC algorithm were more likely to overclassify surgical wounds. 13 Another explanation for SWC discordance and variability identified in this study could be explained by the process of SWC ascertainment, including who is determining SWC and when this process is occurring. The SWC should reflect the clinical information relevant to each operation, and failure to consider this information during an operation potentially leads to classification errors.…”

Section: Discussionmentioning

confidence: 76%

“…Guidelines that are easy to follow should lead to consistent classification, however, disagreement has been noted among surgeons and between surgeons, circulating nurses, and NSQIP reviewers in earlier evaluations of SWC reliability. 13,18 There are limitations to this study. First, although there was an algorithm in place to guide reviewer SWC determination, it is possible that the reviewer did not use or inappropriately used the algorithm.…”

Section: Discussionmentioning

confidence: 94%

“…4,8,9 Additionally, SSI rates are commonly stratified by SWC in the literature to describe and categorize study outcomes. 3,[10][11][12][13] Although SWC is routinely used, the classification of a wound as clean, clean-contaminated, contaminated, or dirty is not always consistent among health care providers. 3 Additionally, the validity and reliability of SWC has not been well studied.…”

mentioning

confidence: 99%

See 2 more Smart Citations

Surgical Wound Misclassification: A Multicenter Evaluation

Levy

Lally

Blakely

et al. 2015

Journal of the American College of Surgeons

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Section: Discussionmentioning

confidence: 76%

Section: Discussionmentioning

confidence: 94%

mentioning

confidence: 99%

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Surgical Wound Misclassification: A Multicenter Evaluation

Levy

Lally

Blakely

et al. 2015

Journal of the American College of Surgeons

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“…It may be expected that in the context of a randomized trial minor wound complications may be more likely to be noted compared to retrospective single center studies, 19 however, trained NSQIP nurse clinical reviewers ability to detect surgical site infection has been previously demonstrated. 20 Intraoperative blood loss was noted to be less with pEVAR in one report 11 , while other studies report similar blood loss for both groups 6, 7 . Our study shows that the need for intra- and postoperative transfusion is similar in both groups.…”

Section: Discussionmentioning

confidence: 81%

Percutaneous versus femoral cutdown access for endovascular aneurysm repair

Buck

Karthaus

Soden

et al. 2015

Journal of Vascular Surgery

104

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Objective Prior studies suggest that percutaneous access for endovascular abdominal aortic aneurysm repair (pEVAR) offers significant operative and post-operative benefits compared to femoral cutdown (cEVAR). National data on this topic, however, are limited. We compared patient selection and outcomes for elective pEVAR and cEVAR. Methods We identified all patients undergoing either pEVAR (bilateral percutaneous access whether successful or not) or cEVAR (at least one planned groin cutdown) for abdominal aortic aneurysms (AAA), from January 2011 to December 2013 in the Targeted Vascular dataset from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Emergent cases, ruptures, cases with an iliac conduit, and cases with a preoperative wound infection were excluded. Groups were compared using chi-square test or t-test or the Mann-Whitney test where appropriate. Results 4112 patients undergoing elective EVAR were identified; 3004 cEVAR (73%) and 1108 pEVAR (27%). Of all EVAR patients 26% had bilateral percutaneous access, 1.0% had attempted percutaneous access converted to cutdown (4% of pEVARs), while the remainder had a planned cutdown, 63.9% bilateral, and 9.1% unilateral. There were no significant differences in age, gender, aneurysm diameter or prior open abdominal surgery. Patients undergoing cEVAR were less likely to have congestive heart failure (1.5% vs. 2.4%, P=0.04) but more likely to undergo any concomitant procedure during surgery (32% vs. 26%, P<.01) than patients undergoing pEVAR. Postoperatively, pEVAR patients had shorter operative time (mean 135 vs. 152 minutes, P<.01), shorter length of stay (median 1 day vs. 2 days, P<.01), and fewer wound complications (2.1% vs. 1.0%, P=0.02). On multivariable analysis the only predictor of percutaneous access failure was performance of any concomitant procedure (OR 2.0, 95% CI 1.0–4.0, P=0.04). Conclusions Currently, 1 in 4 patients treated at Targeted Vascular NSQIP centers are getting pEVAR, which is associated with a high success rate, shorter operation time, shorter length of stay, and fewer wound complications compared to cEVAR.

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“…Given the consistent correlation between SWC and outcomes, researchers, hospitals, quality improvement organizations, and third party payers often use SWC as a method of risk stratification for SSI and postoperative complications[7–9]. Despite this fact, the current literature demonstrates significant inaccuracies in the reporting of wound classification, especially in pediatric cases[1,10,11]. …”

Section: Introductionmentioning

confidence: 99%

Pediatric surgeon–directed wound classification improves accuracy

Zens

Rusy

Gosain

2016

Journal of Surgical Research

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Background Surgical wound classification (SWC) communicates the degree of contamination in the surgical field and is used to stratify risk of surgical site infection and compare outcomes amongst centers. We hypothesized that changing from nurse-directed to surgeon-directed SWC during a structured operative debrief we will improve accuracy of documentation. Methods An IRB-approved retrospective chart review was performed. Two time periods were defined: initially, SWC was determined and recorded by the circulating nurse (Pre-Debrief 6/2012-5/2013) and allowing six months for adoption and education, we implemented a structured operative debriefing including surgeon-directed SWC (Post-Debrief 1/2014-8/2014). Accuracy of SWC was determined for four commonly performed Pediatric General Surgery operations: inguinal hernia repair (clean), gastrostomy +/− Nissen fundoplication (clean-contaminated), appendectomy without perforation (contaminated), and appendectomy with perforation (dirty). Results 183 cases Pre-Debrief and 142 cases Post-Debrief met inclusion criteria. No differences between time periods were noted in regards to patient demographics, ASA class, or case mix. Accuracy of wound classification improved Post-Debrief (42% vs. 58.5%, p=0.003). Pre-Debrief, 26.8% of cases were overestimated or underestimated by more than one wound class, vs. 3.5% of cases Post-Debrief (p<0.001). Interestingly, the majority of Post-Debrief contaminated cases were incorrectly classified as clean-contaminated. Conclusions Implementation of a structured operative debrief including surgeon-directed SWC improves the percentage of correctly classified wounds and decreases the degree of inaccuracy in incorrectly classified cases. However, following implementation of the debriefing, we still observed a 41.5% rate of incorrect documentation, most notably in contaminated cases, indicating further education and process improvement is needed.

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Wound Classification in Pediatric General Surgery: Significant Variation Exists among Providers

Cited by 20 publications

References 18 publications

Surgical Wound Misclassification: A Multicenter Evaluation

Surgical Wound Misclassification: A Multicenter Evaluation

Percutaneous versus femoral cutdown access for endovascular aneurysm repair

Pediatric surgeon–directed wound classification improves accuracy

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