An audit and feedback program can decrease wound classification errors

Sydne Muratore, University of Minnesota; Stacy Carda, RN, BSN, University of Minnesota Health ; Jill Thurston RN, BSN, CPAN, University of Minnesota Health; Alyssia Mills-Hokanson, RN, University of Minnesota Health; Mary Kwaan, MD, MPH, University of Minnesota

Accurate wound classification is an important component of surgical site infection (SSI) risk-adjustment models.  At our institution, protocols direct the circulating nurse to finalize and record wound class in the electronic health record after a "debrief" process with the surgeon, however the accuracy of this process is unknown.

Periodic audit of wound classification, with feedback to individual surgeons and systems interventions, can increase wound classification accuracy.

A prospective wound classification audit and feedback project was performed through the NSQIP program for all cases at an academic hospital. 

Audit: Each month, adult cases from all speciaties performed during a 7 day time frame were reviewed.   Procedure title and wound classification assignment were reviewed for potential discrepances. Endoscopic procedures, with the exception of percutaneous endoscopic gastrostomy procedures, were excluded.
Feedback:  When a discrepancy was detected, the surgeon champion sent a notification to the operating surgeon with review of CDC wound classification definitions.
Study end point: Monthly discrepancy rates were assessed with the one-sided Cochran-Armitage Trend Test.  Feedback interventions concluded when the discrepancy rate reached a nadir.

Over 13 months, 3104 cases were reviewed (mean 239 (SD 26) cases per month). The wound classification discrepancy rate was 8.1% at the start of the project and 1.9% at the conclusion of the project, with 159 discrepancies in total.  Inapppropriate classification of bowel and genitourinary cases as class I instead of class II accounted for 62% of cases.  Under-classification of contaminated or dirty cases (class III/IV) accounted for 38% of cases.  Of the 175 class III/IV cases performed during the audit, 34% were misclassified. A clear decrease in the rate was not seen until after 7 months.  Overall, a decrease in discrepancies was seen (p=0.037; Figure 1), however 3 months after feedback stopped, the rate increased slightly (p=0.16).

An audit/feedback system can increase surgeon attention on the wound classification of cases, however improvement is slow and may require ongoing feedback in order to be sustained.