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Solutions to Intraoperative Wound Classification Miscoding in a Subset of American College of Surgeons National Surgical Quality Improvement Program Patients

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Intraoperative wound classification is a predictor of postoperative infection. Therefore, accurately assigning the correct classification to a surgical wound is of particular importance. Our institution participates in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), a national outcomes database that collects wound classification for all qualifying operative procedures, and we noted discrepancies when comparing ACS NSQIP wound classification coding with perioperative coding in our electronic medical record. We tested the effectiveness of an intervention that included staff educational sessions, informational posters, and postoperative debriefings on improving the accuracy of documented intraoperative wound classification. The χ2 test was used to compare proportions of wound classification miscodings before and after educational sessions and debriefings commenced. Baseline data revealed misclassification of wounds occurred 21 per cent (30 of 141) of the time in predominately colorectal procedures performed by two surgeons from April through August 2012. Errors decreased to 9 per cent (13 of 147) from August to December 2012, after our intervention of education sessions with operating room staff and the surgeons incorporating a statement confirming the wound classification at the end of the case debriefing. The χ2 statistic was 8.7589. The P value was significant at 0.003. Ensuring concordance of classification between the surgeon and nurse during a postprocedure debriefing as well as education of perioperative nursing staff through posters and seminars significantly improved the accuracy of intraoperative wound classification coding.
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Document Type: Research Article

Affiliations: Department of Surgery, University of Virginia, Charlottesville, Virginia, USA

Publication date: 01 February 2015

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  • The Southeastern Surgical Congress owns and publishes The American Surgeon monthly. It is the official journal of the Congress and the Southern California Chapter of the American College of Surgeons, which all members receive each month. The journal brings up to date clinical advances in surgical knowledge in a popular reference format. In addition to publishing papers presented at the annual meetings of the associated organizations, the journal publishes selected unsolicited manuscripts. If you have a manuscript you'd like to see published in The American Surgeon select "Information for Authors" from the Related Information options below. A Copyright Release Form must accompany all manuscripts submitted.
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