Quality check of a quality measure: surgical wound classification discrepancies impact risk-stratified surgical site infection rates in pediatric appendicitis

Abstract

Background: The impact of quality measures in health care and reimbursement is growing. Ensuring the accuracy of quality measures, including any risk-stratification variables, is necessary. Surgical site infection rates, risk stratified by surgical wound classification (SWC) among other variables, are increasingly considered as quality measures. We hypothesized that hospital-documented and diagnosis-based SWCs are frequently discordant and that diagnosis-based SWCs better predict surgical site infection rates.

Study design: All pediatric patients (ie, younger than 18 years old) at a single institution who underwent an appendectomy for appendicitis between October 1, 2010 and August 31, 2011 were included. Each chart was reviewed to determine the hospital-documented SWC, which is recorded by the circulating nurse (options included clean, clean-contaminated, contaminated, and dirty); SWC based on the surgeons' postoperative diagnosis, including contaminated (ie, acute nonperforated, nongangrenous appendicitis), dirty (ie, gangrenous and perforated appendicitis), and 30-day postoperative surgical site infections.

Results: Of the 312 evaluated appendicitis cases, the diagnosis-based and circulating nurse-based SWCs differed in 288 (92%) cases. The circulating nurse-based and diagnosis-based SWCs differed by more than one SWC in 176 (56%) cases. Surgical site infections were associated with worsening diagnosis-based SWC, but not with circulating nurse-based SWC.

Conclusions: Significant discordance exists between hospital documentation by the circulating nurse- and surgeon diagnosis-based SWCs. Inconsistency in risk-stratified quality measures can have a significant effect on outcomes measures, which can lead to misdirection of quality-improvement efforts, incorrect inter-hospital rating, reduced reimbursements, and public misperceptions about quality of care.