During surgical operations, surgical wounds are classified according to the wound classification system (I - clean; II - clean/contaminated; III - contaminated; and IV - dirty). Accuracy in assessing the degree of wound contamination is crucial since it greatly impacts the risk of a surgical site infection (SSI). Thus, wound classifications (WC) are determinant in calculating the expected number of SSIs. At our institution we suspected that surgical wounds were not always accurately classified, and were skewed towards under-classifying wound class. This contributed to incorrect and reduced expected SSIs and an inflated SSI Standardized Infection Ratio (SIR).
An independent team reviewed 273 surgical cases from our top priority SSI reduction areas: Prosthetic knees (KPRO), coronary artery bypass grafts (CABG), abdominal hysterectomies (HYST) and colorectal surgery (COLO). Whenever there was discordance in surgeon vs review team WC, an arbitrator reviewed the case with the surgeon and corrected misclassified cases as appropriate. Reclassifications were documented in the medical record as well as in the National Healthcare Safety Network (NHSN) system.
Figure 1 shows all WC reviews. Overall, 14% of all surgeries were misclassified and 95% of misclassifications were under-classifications. Appropriateness of WC varied widely by surgical service, with 100% concordant WC for KPRO, while 9% of HYST and CABG were misclassified, and fully 38% of COLOs were misclassified (Figure 1). These errors led to under predicting expected SSIs and, if not corrected, would have a measurable impact on our SSI SIR.
The inaccurate classifications vary by service/surgery, but in COLO we found them to be common and overwhelmingly skewed towards under-classification, which had a measurable impact on the number of expected SSIs and on SSI SIR. Focusing efforts on surgeries more prone to misclassification (such as COLO rather than KPRO) may be a worthwhile focused quality improvement effort.
E. Wise, None
A. Boldyga, None
K. Nachman, None
B. T. Gomez, None
J. P. Parada, Merck: Speaker's Bureau , Speaker honorarium .