Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN; Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN.
J Am Coll Surg. 2013 Nov;217(5):819-26. doi: 10.1016/j.jamcollsurg.2013.05.027. Epub 2013 Sep 5.
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).
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.
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).
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.
手术部位感染（SSI）的风险调整率被用作质量指标，以促进医院系统内的改进，并允许在机构之间进行比较。NSQIP-Pediatric 等方法使用手术伤口分类作为模型中的一个变量，用于预测风险调整后的术后发病率，包括 SSI 率。本研究的目的是衡量 3 名提供者（外科医生、手术室护士和 NSQIP 外科临床审查员）之间伤口分类分配的一致性水平。
对 2010 年至 2011 年的小儿普通外科手术进行了分析。伤口分类由手术室护士和外科医生在手术时以及 NSQIP 外科临床审查员术后根据 NSQIP 方法进行分配。意见分歧定义为 3 名提供者之间的任何分类差异，并使用 Kappa 统计确定一致性水平。
在审查的 374 个程序中，所有提供者之间存在总体意见分歧 48%，Kappa 值为 0.48（95%CI 0.43 至 0.53）。当比较外科医生和 NSQIP 外科临床审查员的伤口分类时，23%的病例存在意见分歧，Kappa 值为 0.74（95%CI 0.68 至 0.78）。手术室护士与外科医生或 NSQIP 外科临床审查员之间的意见分歧更大：38%，Kappa 值为 0.45（95%CI 0.38 至 0.53）和 40%，Kappa 值为 0.44（95%CI 0.37 至 0.51）。胃底折叠术、阑尾切除术和胆囊切除术的总体意见分歧最大（分别为 73%、71%和 60%）。
医疗保健提供者在分配手术伤口分类方面存在显著差异。对于未来的 SSI 比较分析，至关重要的是要提高提供者和机构之间在伤口分类分配方面的一致性和理解。
