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Delaplain PT, Santos J, Barie PS, Dvorak J, Mele TS, Gelbard R, Guidry CA, Schubl SD. Self-Reported Diagnosis and Management of Surgical Site Infection Highlights Lack of Objective Measures and Treatment Guidance. Surg Infect (Larchmt) 2023; 24:598-605. [PMID: 37646635 DOI: 10.1089/sur.2023.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
Background: There is little guidance regarding empiric therapy for superficial surgical site infections (SSIs). Management of incisions with signs of SSI lacks consensus and management is variable among individual surgeons. Methods: The Surgical Infection Society was surveyed regarding management of SSIs. Cases were provided with varying wound descriptions, initial wound class (WC), post-operative day, and presence of a prosthesis. Responses were in multiple-choice format; statistics: χ2; α = 0.05. Results: Seventy-eight members responded. For appearance scenarios, respondents believed that both mild erythema (55%) and clear drainage (64%) could be observed, whereas substantial (>3 cm) erythema or purulence should be treated with complete (22% and 50%) or partial (55% and 40%) opening of the incision. Degree of erythema did not influence administration of antibiotic agents, but purulence was more likely than clear drainage to be treated with antibiotics (38% vs. 6%; p < 0.001). There were no differences based on WC, except that clean cases were more likely than higher WC scenarios to be treated with gram-positive coverage alone (WC 1 [26%] vs. 2 [10%] vs. 3 [13%] vs. 4 [4%]; p < 0.001). Post-operative day (POD) three appeared to be an inflection point for more aggressive treatment of suspected incisional SSI, with fewer (POD 0 [86%] vs. POD day 3 [54%]; p < 0.001) reporting observation. Respondents were more likely to obtain imaging, start broad-spectrum antibiotic agents, and return to the operating room for purulence in the presence of a mesh. Conclusions: Presented with escalating possibility of SSI, respondents reported lower rates of observation, increased use of antibiotic agents, and increased surgical drainage. Many scenarios lack consensus regarding appropriate therapy. The complete elimination of SSIs is unlikely to be accomplished soon, and this study provides a framework for understanding how surgeons approach SSIs, and potential areas for further research or pragmatic guidance.
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Affiliation(s)
- Patrick T Delaplain
- Department of Surgery, Boston Children's Hospital, Harvard Medical System, Boston, Massachusetts, USA
| | - Jeffrey Santos
- Department of Surgery, University of California-Irvine, Orange, California, USA
| | - Philip S Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York USA
| | - Justin Dvorak
- Department of Surgery, Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Tina S Mele
- Divisions of General Surgery and Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Rondi Gelbard
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Christopher A Guidry
- Division of Acute Care Surgery, Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California-Irvine, Orange, California, USA
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Santos J, Delaplain PT, Barie PS, Dvorak J, Mele TS, Gelbard R, Guidry CA, Schubl SD. Different Surgeon, Different Closure: Lack of Consensus on Appropriate Closure Technique for Various Case Scenarios. Surg Infect (Larchmt) 2023; 24:541-548. [PMID: 37462905 DOI: 10.1089/sur.2023.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
Background: Many techniques for closure of surgical incisions are available to the surgeon, but there is minimal guidance regarding which technique(s) should be utilized at the conclusion of surgery and under what circumstances. Hypothesis: Management of incisions at the conclusion of surgery lacks consensus and varies among individual surgeons. Methods: The Surgical Infection Society membership was surveyed on the management of incisions at the conclusion of surgery. Several case scenarios were provided to test the influences of operation type, intra-operative contamination, and hemodynamic stability on incision management (e.g., close fascia or skin, use of incision/wound vacuum-assisted closure [VAC] device). Responses by two-thirds of participants were required to achieve consensus. Data analysis by χ2 test and logistic regression, a = 0.05. Response heterogeneity was quantified by the Shannon index (SI). Results: Among 78 respondents, consensus was achieved for elective splenectomy (91% close skin/dry dressing). Open appendectomy and left colectomy/end-colostomy had the greatest heterogeneity (SI, 1.68 and 1.63, respectively). During trauma laparotomy, the majority used damage control for hemodynamic instability (53%-67%) but not for hemodynamically stable patients (0%-1.3%; p < 0.001). Additional consensus was achieved for close skin/dry dressing for hemodynamically stable trauma splenectomy patients (87%) and fascia open/wound VAC for hemodynamically unstable colon resection/anastomosis (67%). Fecal diversion for rectal injury and colon resection/anastomosis (both when hemodynamically stable) had high heterogeneity (SI, 1.56 and 1.48, respectively). In penetrating trauma, sentiment was for more use of wet-to-dry dressings and incision/wound VAC with increased contamination in hemodynamically stable patients. Conclusions: Damage control was favored in hemodynamically unstable trauma patients, with use of wet-to-dry dressings and incision/wound VAC with spillage after penetrating trauma. However, most scenarios did not achieve consensus. High variability of practices regarding incision management at the conclusion of surgery was confirmed. Prospective studies and evidence-based guidance are needed to guide decision making at end-operation.
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Affiliation(s)
- Jeffrey Santos
- Department of Surgery, University of California-Irvine, Orange, California, USA
| | - Patrick T Delaplain
- Department of Surgery, Boston Children's Hospital, Harvard Medical System, Boston, Massachusetts, USA
| | - Philip S Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Justin Dvorak
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Tina S Mele
- Divisions of General Surgery and Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Rondi Gelbard
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Christopher A Guidry
- Division of Acute Care Surgery, Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Sebastian D Schubl
- Department of Surgery, University of California-Irvine, Orange, California, USA
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O'Brien MS, Gupta A, Quevedo A, Lenger SM, Shah V, Warehime J, Gaskins J, Biscette S. Postoperative Complications of Appendectomy in Gynecologic Laparoscopic Surgery for Benign Indications. Obstet Gynecol 2023; 141:354-360. [PMID: 36649317 DOI: 10.1097/aog.0000000000005033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/17/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To assess whether concomitant appendectomy in patients who undergo laparoscopic surgery for benign gynecologic indications is associated with increased rates of complications in the 30-day postoperative period. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent laparoscopic surgery by a gynecologist. Patients were excluded if they underwent open abdominal surgeries, bowel resections, urogynecologic surgeries, or if diagnoses of cancer or appendicitis were present. There were 246,987 patients included in the population cohort from 2010 to 2020. Demographic information and postoperative outcomes of patients who underwent concomitant appendectomy were compared with patients who did not undergo appendectomy. A matched cohort was created by computing propensity scores, and outcomes were again compared between groups. All patients undergoing appendectomy were 1:1 matched to a unique patient who did not undergo appendectomy using a greedy matching based on the propensity score calculated from demographic and surgical characteristics. RESULTS A total of 1,760 patients (0.7%) underwent concomitant appendectomy. There was an 8.0% complication rate in the appendectomy group, compared with 5.5% in the group of those without appendectomy ( P <.001), and this was similar to the results in the propensity-matched sample. Patients who underwent appendectomy had significantly higher rates of readmission (4.3% vs 2.3%), which remained significant in the propensity-matched sample. There were no differences in the rates of postoperative thromboembolic events, blood transfusion, or reoperation. CONCLUSION Patients who are undergoing concomitant appendectomy have an increased risk of any complication and hospital readmission. Additional studies may be conducted to identify patients with optimal risk benefit profiles when considering performing concomitant appendectomy at time of gynecologic surgery.
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Affiliation(s)
- M Shea O'Brien
- Department of Obstetrics, Gynecology, and Women's Health, the Department of Urogynecology, Female Pelvic Medicine and Reconstruction, the Department of Minimally Invasive Gynecologic Surgery, and the School of Public Health and Information Science, University of Louisville, Louisville, Kentucky
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A Comparison of Interobserver Reliability Between Orthopedic Surgeons Using the Centers for Disease Control Surgical Wound Class Definitions. J Am Acad Orthop Surg 2021; 29:1068-1071. [PMID: 33945517 DOI: 10.5435/jaaos-d-20-01128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/05/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Centers for Disease Control (CDC) created a classification to help stratify surgical wounds based on contamination and risk of developing a surgical site infection. The classification includes four options (I to IV) depending on the level of contamination present. Although universally applied to a variety of surgical specialties, it is unknown whether the current system is reliable when considering orthopaedic surgeries. The purpose of this study was to compare the degree of interobserver reliability between orthopaedic surgeons using the current CDC wound class definitions. METHODS A questionnaire containing 30 clinical vignettes was completed by 39 orthopaedic surgeons at our institution. After each vignette, respondents were asked to determine the appropriate wound class based on information provided in the vignette. The overall interobserver agreement among all participants was analyzed. In addition, respondents were queried about the adequacy of the current classification system in describing orthopaedic surgical wound class. RESULTS Interobserver agreement was poor at 66%, with a coefficient of concordance of 0.48. Only six physicians (15.4%) thought that the current wound classification system adequately covered orthopaedic surgery. CONCLUSIONS There is poor interobserver reliability using the CDC surgical wound class definitions for orthopaedic surgeries. Alternate definitions are needed to improve the validity of the system for subspecialty procedures.
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Massoumi RL, Wertz J, Anderson N, Barrett N, Jen HC. Wound Classification Score Discordance in Pediatric Operations - A Quality Improvement Study. J Surg Res 2021; 268:681-686. [PMID: 34482008 DOI: 10.1016/j.jss.2021.06.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 05/04/2021] [Accepted: 06/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Wound classification scores are used to categorize the risk of postoperative infections. It was noted at our academic institution that wound classifications were often inaccurately recorded in the electronic health record. We thus instituted a quality improvement program, hypothesizing that this would improve charting accuracy. METHODS On June 1, 2019, we posted the wound classifications in each pediatric operating room (OR), provided OR nurses with teaching, and began including the classification in the postoperative surgeon debriefing. We performed a retrospective chart review of all general pediatric operations from June 19 to December 19 to compare classifications recorded in the electronic health record to the "correct" classification determined by manual review of operating reports. These data were compared with a similar chart review from 2018. To compare the efficacy of nursing versus physician focused changes, we compared our appendectomy data with a nearby community institution where the same group of surgeons practice. Pearson's Chi-squared test was used to report the significance of the differences observed in the concordance proportion, with 95% confidence intervals calculated using the Clopper-Pearson procedure. RESULTS Overall, 444 pre- and 179 postpractice change charts were reviewed. There were no significant differences pre or postpractice change. At the community institution, we noted a significant improvement in charting accuracy for appendectomies from 3.33% to 44.83%. DISCUSSION Despite implementing nursing and physician focused quality improvement practices, there was not a significant improvement in charting accuracy at the academic institution. However, we did note an improvement at the community facility where our pediatric surgeons also practice. We thus suspect that our nursing focused changes may have been inadequate. Future efforts will focus on providing intensive and sustained OR nurse training to help improve the wound classification charting accuracy.
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Affiliation(s)
- Roxane L Massoumi
- UCLA David Geffen School of Medicine, Department of General Surgery, Los Angeles, California
| | - Joseph Wertz
- UCLA David Geffen School of Medicine, Los Angeles, California
| | | | | | - Howard C Jen
- Mattel Children's Hospital at UCLA, Division of Pediatric Surgery, Los Angeles, California.
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Zarei M, Larti N, Tabesh H, Ghasembandi M, Aarabi A. Does Plastic Incise Drape Prevent Recolonization of Endogenous Skin Flora during Lumbar Spine Procedures? Int J Prev Med 2020; 10:162. [PMID: 32133080 PMCID: PMC6826676 DOI: 10.4103/ijpvm.ijpvm_133_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 08/11/2019] [Indexed: 11/27/2022] Open
Abstract
Background: The aim of this study was to compare the PID with bare skin (without PID) regarding bacterial recolonization and bacterial regrowth of the adjacent skin of surgical incision in lumbar spine surgery patients. Methods: This quasi-experimental study was conducted from February to May 2018 on 88 patients who were candidate for lumbar spine surgery. Patients were assigned to one of two groups, treatment (with PID) and control (without PID). Skin sampling (adjacent of surgical incision) for bacterial culture was done in two steps, immediately after surgical skin prep (IASSP) and immediately after surgical wound closure (IASWC) by researcher. Finally, samples were sent to the laboratory. Results: The mean total bacterial count of patient's skin in stage IASSP was not significantly different between treatment and control groups (0.34 vs 0.27, P = 0.68). However, mean total bacterial count in stage IASWC in treatment group was significantly higher than control group (2.2 vs 0.93, P = 0.03). The frequency distribution of S. aureus (P = 0.04) and S. epidermidis (P = 0.02) was significantly higher in treatment group compared with control group in stage IASWC. Conclusions: The results showed that using PID is unable to reduce recolonization and regrowth of bacteria on patients’ skin adjacent to surgical wound in clean lumbar spine surgeries. However, making a definite decision about using or not using of PID requires further studies.
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Affiliation(s)
- Mohammadreza Zarei
- Department of Operating Room, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Negin Larti
- Department of Operating Room, School of Paramedical Sciences, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Homayoun Tabesh
- Department of Neurosurgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Ghasembandi
- Department of Operating Room, School of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Isfahan, Iran
| | - Akram Aarabi
- School of Nursing and Midwifery, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Stefanou A, Worden A, Kandagatla P, Reickert C, Rubinfeld I. Surgical Wound Misclassification to Clean From Clean-Contaminated in Common Abdominal Operations. J Surg Res 2019; 246:131-138. [PMID: 31580983 DOI: 10.1016/j.jss.2019.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 07/28/2019] [Accepted: 09/03/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Wound classification helps predict wound-related complications and is useful in stratifying surgical site infection reporting. We sought to evaluate misclassification among commonly performed surgeries that are at least clean-contaminated. MATERIALS AND METHODS The National Surgical Quality Improvement Program database was queried from 2005 to 2016 by Current Procedural Terminology codes identifying common surgeries that are, by definition, not clean: colectomy, cholecystectomy, hysterectomy, and appendectomy. Univariate analysis and multivariate logistic regression were performed. RESULTS Of the 1,208,544 operative cases reviewed, 22,925 (1.90%) were misclassified as clean. Hysterectomy was the most commonly misclassified operation (3.11%), and colectomy the least (0.82%). Misclassification was higher in laparoscopic cases (1.92% versus 1.82%; P < 0.01). Misclassification increased from 2005 to 2016 (0.22% versus 3.11%; P < 0.01). Misclassified patients were younger (46.7 versus 47.7 y; P < 0.01); had lower rates of hypertension, chronic obstructive pulmonary disease, smoking history, and steroid use (P < 0.01); and had shorter length of stay (2.2 versus 3.2 d; P < 0.01), lower 30-d readmission rates (3.7% versus 5.0%; P < 0.01), and less surgical site infections (1.7% versus 3.4%; P < 0.01). Open hysterectomy was the most significant positive predictor for misclassification (odds ratio 3.34; P < 0.01). Open appendectomy was the most significant negative predictor (odds ratio 0.20; P < 0.01). CONCLUSIONS There is an increasing trend of misclassifying wounds as clean. Misclassified patients have better outcomes, and misclassification may be affected by patient characteristics, operative approach, and type of procedure rather than reflecting the true infectious burden. Further research is warranted.
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Affiliation(s)
- Amalia Stefanou
- Department of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan.
| | - Andrew Worden
- Department of General Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Pridvi Kandagatla
- Department of General Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Craig Reickert
- Department of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Ilan Rubinfeld
- Department of General Surgery, Henry Ford Hospital, Detroit, Michigan
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Mariage M, Sabbagh C, Grelpois G, Prevot F, Darmon I, Regimbeau JM. Surgeon's Definition of Complicated Appendicitis: A Prospective Video Survey Study. Euroasian J Hepatogastroenterol 2019; 9:1-4. [PMID: 31988858 PMCID: PMC6969325 DOI: 10.5005/jp-journals-10018-1286] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim Definition of the type of appendicitis is based on examination of the peritoneum and appendix. Gomes et al. proposed a laparoscopic grading system of acute appendicitis (grades 1 and 2, noncomplicated appendicitis, grade 3-5 complicated appendicitis). The aim of this study was to evaluate the reproducibility of this score. Patients and methods All patients managed for acute appendicitis between January 2016 and June 2016 were included in this single-center prospective study. Laparoscopic appendectomy procedures were filmed by analogy to Sugerbaker's peritoneal carcinomatosis score (9 quadrants, all of the abdomen was filmed). The videos were then analyzed by seven staff surgeons blinded to each other and the operative report. The primary endpoint was to determine the concordance between staff surgeons for grading of appendicitis using the laparoscopic grading system of acute appendicitis described by Gomes et al. Results A total of 40 patients were included in this study. A concordance was observed between the seven staff surgeons in 85% of cases. For regional peritonitis, the mean ± (SD) number of quadrants in which the staff surgeons reported signs of peritonitis was 1.44 ± 0.63. For diffuse peritonitis, the mean (SD) number of quadrants in which the staff surgeons reported signs of peritonitis was 2.59 ± 0.51. On ROC curve analysis, two quadrants was the best cut-off between grade 4B (local peritonitis) and five (diffuse peritonitis) acute appendicitis (AUC = 0.92, Se = 100%, Sp = 92%, p = 0.005). Conclusion The classification used to determine the type of appendicitis is reproducible. Clinical significance To give a definition of complicated appendicitis. How to cite this article Mariage M, Sabbagh C, et al. Surgeon's Definition of Complicated Appendicitis: A Prospective Video Survey Study. Euroasian J Hepatogastroenterol 2019;9(1):1-4.
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Affiliation(s)
- Maxime Mariage
- Department of Digestive Surgery, University Hospital of Amiens, Amiens, Hautsde France, France
| | - Charles Sabbagh
- Department of Digestive Surgery, University Hospital of Amiens, Amiens, Hautsde France, France
| | - Gerard Grelpois
- Department of Digestive Surgery, University Hospital of Amiens, Amiens, Hautsde France, France
| | - Flavien Prevot
- Department of Digestive Surgery, University Hospital of Amiens, Amiens, Hautsde France, France
| | - Ilan Darmon
- Department of Digestive Surgery, University Hospital of Amiens, Amiens, Hautsde France, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, University Hospital of Amiens, Amiens, Hautsde France, France
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Gorvetzian JW, Epler KE, Schrader S, Romero JM, Schrader R, Greenbaum A, McKee R. Operating room staff and surgeon documentation curriculum improves wound classification accuracy. Heliyon 2018; 4:e00728. [PMID: 30109278 PMCID: PMC6088459 DOI: 10.1016/j.heliyon.2018.e00728] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 06/08/2018] [Accepted: 08/03/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Misclassification of wounds in the operating room (OR) can adversely affect surgical site infection (SSI) reporting and reimbursement. This study aimed to measure the effects of a curriculum on documentation of surgical wound classification (SWC) for operating room staff and surgeons. METHODS Accuracy of SWC was determined by comparing SWC documented by OR staff during the original operation to SWC determined by in-depth chart review. Patients 18 years or older undergoing inpatient surgical procedures were included. Two plan-do-act-study (PDSA) cycles were implemented over the course of 9 months. A total of 747 charts were reviewed. Accuracy of SWC documentation was retrospectively assessed across 248 randomly selected surgeries during a 5-week period prior to interventions and compared to 244 cases and 255 cases of post-intervention data from PDSA1 and PDSA2, respectively. Changes in SWC accuracy were assessed pre- and post-intervention using the kappa coefficient. A p-value for change in agreement was computed by comparing pre- and post-intervention kappa. RESULTS Inaccurate documentation of surgical wound class decreased significantly following curriculum implementation (kappa improved from 0.553 to 0.739 and 0.757; p = 0.001). Classification accuracy improved across all wound classes; however, class III and IV wounds were more frequently misclassified than class I and II wounds, both before and after the intervention. CONCLUSION Implementation of a multidisciplinary documentation curriculum resulted in a significant decrease in SWC documentation error. Improved accuracy of SWC reporting may facilitate a better assessment of SSI risk in a complex patient population.
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Affiliation(s)
| | | | - Samuel Schrader
- University of New Mexico, School of Medicine, Albuquerque, NM, USA
| | - Joshua M. Romero
- University of New Mexico, School of Medicine, Albuquerque, NM, USA
| | | | - Alissa Greenbaum
- University of New Mexico, Department of Surgery, Albuquerque, NM, USA
| | - Rohini McKee
- University of New Mexico, Department of Surgery, Albuquerque, NM, USA
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Toyoshima Y, Maeda T, Kijima T, Namiki O, Nemoto T, Inagaki K. Therapeutic failure and eventual solution for skin necrosis and exposed tendon of the dorsum of the foot: A case report. Clin Case Rep 2018; 6:1600-1603. [PMID: 30147913 PMCID: PMC6099008 DOI: 10.1002/ccr3.1697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 06/08/2018] [Indexed: 11/18/2022] Open
Abstract
For the treatment of skin necrosis with exposed tendons in rheumatoid arthritis (RA) foot, we should perform microvascular free flap surgery at an early stage without conservative treatment considering the increased risk of infection and the decreased physical activity.
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Affiliation(s)
- Yoichi Toyoshima
- Department of Orthopaedic SurgeryShowa University School of MedicineShinagawa‐ku, TokyoJapan
| | - Toshio Maeda
- Department of Orthopaedic SurgeryShowa University School of MedicineShinagawa‐ku, TokyoJapan
| | - Takeshi Kijima
- Department of Orthopaedic SurgeryShowa University School of MedicineShinagawa‐ku, TokyoJapan
| | - Osamu Namiki
- Department of Orthopaedic SurgeryShowa University School of MedicineShinagawa‐ku, TokyoJapan
| | - Tetsuya Nemoto
- Department of Orthopaedic SurgeryShowa University School of MedicineShinagawa‐ku, TokyoJapan
| | - Katsunori Inagaki
- Department of Orthopaedic SurgeryShowa University School of MedicineShinagawa‐ku, TokyoJapan
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The American Association for the Surgery of Trauma Emergency General Surgery Anatomic Severity Scoring System as a predictor of cost in appendicitis. Surg Endosc 2018; 32:4798-4804. [PMID: 29777350 DOI: 10.1007/s00464-018-6230-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 05/09/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND The World Society for Emergency Surgery determined that for appendicitis managed with appendectomy, there is a paucity of evidence evaluating costs with respect to disease severity. The American Association for the Surgery of Trauma (AAST) disease severity grading system is valid and generalizable for appendicitis. We aimed to evaluate hospitalization costs incurred by patients with increasing disease severity as defined by the AAST. We hypothesized that increasing disease severity would be associated with greater cost. METHODS Single-institution review of adults (≥ 18 years old) undergoing appendectomy for acute appendicitis during 2010-2016. Demographics, comorbidities, operative details, hospital stay, complications, and institutional cost data were collected. AAST grades were assigned by two independent reviewers based on operative findings. Total cost was ascertained from billing data and normalized to median grade I cost. Non-parametric linear regression was utilized to assess the association of several covariates and cost. RESULTS Evaluated patients (n = 1187) had a median [interquartile range] age of 37 [26-55] and 45% (n = 542) were female. There were 747 (63%) patients with Grade I disease, 219 (19%) with Grade II, 126 (11%) with Grade III, 50 (4%) with Grade IV, and 45 (4%) with Grade V. The median normalized cost of hospitalization was 1 [0.9-1.2]. Increasing AAST grade was associated with increasing cost (ρ = 0.39; p < 0.0001). Length of stay exhibited the strongest association with cost (ρ = 0.5; p < 0.0001), followed by AAST grade (ρ = 0.39), Clavien-Dindo Index (ρ = 0.37; p < 0.0001), age-adjusted Charlson score (ρ = 0.31; p < 0.0001), and surgical wound classification (ρ = 0.3; p < 0.0001). CONCLUSIONS Increasing anatomic severity, as defined by AAST grade, is associated with increasing cost of hospitalization and clinical outcomes. The AAST grade compares favorably to other predictors of cost. Future analyses evaluating appendicitis reimbursement stand to benefit from utilization of the AAST grade.
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