Putnam Luke R, Levy Shauna M, Holzmann-Pazgal Galit, Lally Kevin P, Lillian S Kao, Tsao KuoJen
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.
Children's Memorial Hermann Hospital, Houston, TX; Department of Infectious Diseases, University of Texas Health Science Center at Houston, Houston, TX.
J Pediatr Surg. 2015 Jun;50(6):915-8. doi: 10.1016/j.jpedsurg.2015.03.008. Epub 2015 Apr 1.
BACKGROUND/PURPOSE: 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.
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.
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).
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.
背景/目的：手术伤口分类（SWC）用于对手术部位感染（SSI）进行风险分层，以进行质量报告。我们之前发现，对于急性阑尾炎，基于医院的SWC与基于诊断的SWC之间仅有8%的一致性。我们假设，通过教育和基于流程的干预措施，可以改善基于医院的SWC报告以及SSI风险分层的有效性。
纳入2011年1月至2013年12月期间因急性阑尾炎接受阑尾切除术的患者（年龄<18岁）。干预措施包括为围手术期人员举办关于SWC的教育研讨会，并将SWC纳入手术安全检查表中的一个检查点。记录术后30天的SSI情况。采用卡方检验、费舍尔精确检验和kappa统计量。
共审查了995例病例（干预前=478例，干预后=517例）。基于医院的SWC与基于诊断的SWC之间的加权评分者间一致性从50%提高到了81%（p<0.01），加权kappa从0.16（95%CI 0.004 - 0.03）提高到了0.29（95%CI 0.25 - 0.34）。仅在干预后时期，基于医院的污染伤口与SSI显著相关（p<0.01）。
经过简单干预后，基于医院的SWC与基于诊断的SWC之间的一致性显著提高，并且SSI风险分层与疾病严重程度的预期增加相一致。尽管有这些改进，但在SWC知识和流程方面仍存在很大差距。
