Quality check of a quality measure: surgical wound classification discrepancies impact risk-stratified surgical site infection rates in pediatric appendicitis.

BACKGROUND: The impact of quality measures in health care and reimbursement is growing. Ensuring the accuracy of quality measures, including any risk-stratification variables, is necessary. Surgical site infection rates, risk stratified by surgical wound classification (SWC) among other variables, are increasingly considered as quality measures. We hypothesized that hospital-documented and diagnosis-based SWCs are frequently discordant and that diagnosis-based SWCs better predict surgical site infection rates. STUDY DESIGN: All pediatric patients (ie, younger than 18 years old) at a single institution who underwent an appendectomy for appendicitis between October 1, 2010 and August 31, 2011 were included. Each chart was reviewed to determine the hospital-documented SWC, which is recorded by the circulating nurse (options included clean, clean-contaminated, contaminated, and dirty); SWC based on the surgeons' postoperative diagnosis, including contaminated (ie, acute nonperforated, nongangrenous appendicitis), dirty (ie, gangrenous and perforated appendicitis), and 30-day postoperative surgical site infections. RESULTS: Of the 312 evaluated appendicitis cases, the diagnosis-based and circulating nurse-based SWCs differed in 288 (92%) cases. The circulating nurse-based and diagnosis-based SWCs differed by more than one SWC in 176 (56%) cases. Surgical site infections were associated with worsening diagnosis-based SWC, but not with circulating nurse-based SWC. CONCLUSIONS: Significant discordance exists between hospital documentation by the circulating nurse- and surgeon diagnosis-based SWCs. Inconsistency in risk-stratified quality measures can have a significant effect on outcomes measures, which can lead to misdirection of quality-improvement efforts, incorrect inter-hospital rating, reduced reimbursements, and public misperceptions about quality of care.

Active surveillance culturing impacts methicillin-resistant Staphylococcus aureus acquisition in a pediatric intensive care unit.

OBJECTIVE: To determine whether active surveillance culturing for methicillin-resistant Staphylococcus aureus (MRSA) decreases nosocomial MRSA acquisition in the pediatric intensive care unit. DESIGN: Before and after observational study. SETTING: A tertiary care, 20-bed, pediatric intensive care unit. PATIENTS: All patients admitted to the pediatric intensive care unit. INTERVENTIONS: Anterior nares cultures for MRSA were obtained on admission and weekly in the pediatric intensive care unit from January 2007 to December 2009 as part of a hospital quality improvement project. MEASUREMENTS AND MAIN RESULTS: MRSA admission prevalence and nosocomial incidence density were determined retrospectively for 2006 and prospectively for 2007-2009. Nosocomial MRSA incidence density during the intervention period was determined monthly and analyzed by trend analysis by using a general linear model. The correlation of active surveillance culturing compliance with nosocomial acquisition of MRSA was analyzed. Possible confounding by healthcare worker hand hygiene compliance observed during the intervention period was also analyzed by multivariate linear regression analysis. The yearly MRSA incidence density significantly decreased from 2006 to 2009 (6.88 per 1,000 patient days to 1.45 per 1,000 patient days, p < .001) and from 2007 to 2009 (7.32 per 1,000 patient days to 1.45 per 1,000 patient days, p < .001). Trend analysis demonstrated a significant decline in MRSA acquisition over time following the introduction of active surveillance culturing (p < .001). Surveillance culturing was significantly associated with the decline in MRSA acquisition observed in the pediatric intensive care unit by multivariate regression analysis when controlling for hand hygiene (p = .01). CONCLUSIONS: Active surveillance culturing resulted in significantly decreased nosocomial acquisition of MRSA in a pediatric intensive care unit setting. Admission and weekly active surveillance culturing appears to be an effective tool to decrease the spread of MRSA in the pediatric intensive care unit, independent of improvement in hand hygiene compliance. The impact on hospital-acquired MRSA infections and the cost benefit of active surveillance culturing require further study.