title: 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.
  
  
  METHODS
  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.
authors.affiliation: Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Center for Surgical Trials and Evidence-Based Practice, Medical School at Houston, Houston, TX.
authors.forename: Shauna M
authors.initials: SM
authors.lastname: Levy
authors.forename: Galit
authors.initials: G
authors.lastname: Holzmann-Pazgal
authors.forename: Kevin P
authors.initials: KP
authors.lastname: Lally
authors.forename: Koya
authors.initials: K
authors.lastname: Davis
authors.forename: Lillian S
authors.initials: LS
authors.lastname: Kao
authors.forename: Kuojen
authors.initials: K
authors.lastname: Tsao
mesh_terms: D000293:Adolescent; D001062:Appendectomy / Q000592:standards*; D001064:Appendicitis / Q000145:classification / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D004282:Documentation; D057286:Electronic Health Records; D006776:Hospitals, Pediatric / Q000592:standards; D006801:Humans; D007223:Infant; D017053:Infection Control / Q000379:methods / Q000592:standards; D020379:Risk Adjustment / Q000379:methods* / Q000592:standards; D013530:Surgical Wound Infection / Q000175:diagnosis / Q000453:epidemiology / Q000451:nursing; D013781:Texas; D016896:Treatment Outcome