title: Wound classification in pediatric general surgery: significant variation exists among providers.
abstract: BACKGROUND
  Risk-adjusted rates of surgical site infections (SSI) are used as a quality metric to facilitate improvement within a hospital system and allow comparison across institutions. The NSQIP-Pediatric, among others, uses surgical wound classification as a variable in models designed to predict risk-adjusted postoperative morbidity, including SSI rates. The purpose of this study was to measure the level of agreement in wound classification assignment among 3 providers: surgeons, operating room (OR) nurses, and NSQIP surgical clinical reviewers (SCR).
  
  
  METHODS
  An analysis was performed of pediatric general surgery operations from 2010 to 2011. Wound classification was assigned at the time of operation by the OR nurse and surgeon, and by the NSQIP SCR postoperatively, according to NSQIP methodology. Disagreement was defined as any discrepancy in classification among the 3 providers, and the level of agreement was determined using the kappa statistic.
  
  
  RESULTS
  For the 374 procedures reviewed, there was an overall disagreement of 48% among all providers, kappa 0.48 (95% CI 0.43 to 0.53). When comparing wound classification by surgeon and NSQIP SCR, 23% of cases were in disagreement, kappa 0.74 (95% CI 0.68 to 0.78). Disagreement between OR nurse and either surgeon or NSQIP SCR was higher: 38%, kappa 0.45 (95% CI 0.38 to 0.53) and 40%, kappa 0.44 (95% CI 0.37 to 0.51). Fundoplication, appendectomy, and cholecystectomy demonstrated the highest overall disagreement (73%, 71%, and 60%, respectively).
  
  
  CONCLUSIONS
  There is significant variation in assigning surgical wound classification among health care providers. For future SSI comparative analyses, it will be critical to improve uniformity and understanding of wound class assignment among providers and institutions.
authors.affiliation: Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN; Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN.
authors.forename: Rebecca A
authors.initials: RA
authors.lastname: Snyder
authors.forename: Lisa
authors.initials: L
authors.lastname: Johnson
authors.forename: Jamie
authors.initials: J
authors.lastname: Tice
authors.forename: Tammy
authors.initials: T
authors.lastname: Wingo
authors.forename: Dana
authors.initials: D
authors.lastname: Williams
authors.forename: Li
authors.initials: L
authors.lastname: Wang
authors.forename: Martin L
authors.initials: ML
authors.lastname: Blakely
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D013502:General Surgery; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D015588:Observer Variation; D010372:Pediatrics; D013530:Surgical Wound Infection / Q000145:classification* / Q000453:epidemiology*
keywords: ACS; ASA; American College of Surgeons; American Society of Anesthesiologists; CPT; Common Procedural Terminology; IQR; NSQIP SCR; National Surgical Quality Improvement Program Surgical Clinical Reviewer; OR; Operating room; RN; Registered nurse; SSI; Surgical site infection; interquartile range