title: Surgical wound classification for pediatric appendicitis remains poorly documented despite targeted interventions.
abstract: OBJECTIVE
  Surgical wound class (SWC) is used to risk-stratify surgical site infections (SSI) for quality reporting. We previously demonstrated only 8% agreement between hospital-based SWC and diagnosis-based SWC for acute appendicitis. We hypothesized that education and process-based interventions would improve hospital-based SWC reporting and the validity of SSI risk stratification.
  
  
  METHODS
  Patients (<18 years old) who underwent appendectomies for acute appendicitis between January 2011 and December 2013 were included. Interventions entailed educational workshops regarding SWC for perioperative personnel and inclusion of SWC as a checkpoint in the surgical safety checklist. Thirty-day postoperative SSIs were recorded. Chi-square, Fisher's exact test, and kappa statistic were utilized.
  
  
  RESULTS
  995 cases were reviewed (pre-intervention=478, post-intervention=517). Weighted interrater agreement between hospital-based and diagnosis-based SWC improved from 50% to 81% (p<0.01), and weighted kappa increased from 0.16 (95% CI 0.004-0.03) to 0.29 (95% CI 0.25-0.34). Hospital-based dirty wounds were significantly associated with SSI in the post-intervention period only (p<0.01).
  
  
  CONCLUSIONS
  Agreement between hospital-based SWC and diagnosis-based SWC significantly improved after simple interventions, and SSI risk stratification became consistent with the expected increase in disease severity. Despite these improvements, there were still substantial gaps in SWC knowledge and process.
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, Departments of Pediatric Surgery and Surgery, The University of Texas Health Science Center at Houston, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX.
authors.forename: Luke R
authors.initials: LR
authors.lastname: Putnam
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, Departments of Pediatric Surgery and Surgery, The University of Texas Health Science Center at Houston, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX.
authors.forename: Shauna M
authors.initials: SM
authors.lastname: Levy
authors.affiliation: Children's Memorial Hermann Hospital, Houston, TX; Department of Infectious Diseases, University of Texas Health Science Center at Houston, Houston, TX.
authors.forename: Galit
authors.initials: G
authors.lastname: Holzmann-Pazgal
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, Departments of Pediatric Surgery and Surgery, The University of Texas Health Science Center at Houston, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX.
authors.forename: Kevin P
authors.initials: KP
authors.lastname: Lally
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, Departments of Pediatric Surgery and Surgery, The University of Texas Health Science Center at Houston, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX.
authors.forename: Kao
authors.initials: K
authors.lastname: Lillian S
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, Departments of Pediatric Surgery and Surgery, The University of Texas Health Science Center at Houston, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX. Electronic address: kuojen.tsao@uth.tmc.edu.
authors.forename: KuoJen
authors.initials: K
authors.lastname: Tsao
mesh_terms: D000293:Adolescent; D001062:Appendectomy; D001064:Appendicitis / Q000601:surgery*; D057189:Checklist; D002648:Child; D002675:Child, Preschool; D004282:Documentation / Q000592:standards*; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D015203:Reproducibility of Results; D012189:Retrospective Studies; D018570:Risk Assessment; D013530:Surgical Wound Infection / Q000175:diagnosis* / Q000209:etiology
keywords: risk stratification; surgical site infection; surgical wound class; wound classification