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Measure Summary
Title
Chronic wound care: percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without the use of a wound surface culture technique.
Source(s)
American Society of Plastic Surgeons, Physician Consortium for Performance Improvement®, National Committee for Quality Assurance. Chronic wound care physician performance measurement set. Chicago (IL): American Medical Association (AMA); 2010 Sep. 35 p. [19 references]

Measure Domain

Primary Measure Domain
Clinical Quality Measures: Process
Secondary Measure Domain
Does not apply to this measure

Brief Abstract

Description

This measure is used to assess the percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without the use of a wound surface culture technique.

Rationale

Infections are a potential complication in any patient with a chronic wound. Accurately determining the pathogenic cause of these clinically diagnosed infections has important implications in determining appropriate treatment regimens and minimizing patient complications. Surface swab cultures are inaccurate and unreliable for obtaining specimens for culture. A surface swab of an unprepared wound bed will not necessarily reveal the organism that resides within the tissue but rather only the surface contaminants. A basic tenet of infection within a chronic wound is that the organism must reside in living tissue. Swab culture of the surface may not reveal this in the presence of significant necrotic tissue or exudate. A recent survey of wound care practitioners in the US found that 54% of respondents routinely collect a swab culture while another 42% routinely collect both swab and biopsy specimens depending on the nature of the wound. More importantly, the study demonstrated considerable variability in the type of swab culture commonly obtained - including surface, deep swab and quantitative techniques. Despite their limited utility and the proven efficacy of quantitative swab and other techniques, surface cultures remain a common method for identifying chronic wound infection. The principle here is to avoid swabbing the unprepared wound exudate. Preparation of the wound with physiologic solution and removal of loose tissue matter prior to obtaining the wound culture will not impede the diagnosis of an offending organism, rather it will lessen the probability of identifying and treating a surface contaminant that will not impact progression to healing. In other words, no information is lost by wound bed preparation prior to swab or tissue biopsy technique culture. The goal is to obtain tissue microorganisms from the viable deeper tissue plane.

The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines and represent the evidence base for the measure:

Avoid swabbing undebrided ulcers or wound drainage. If swabbing the debrided wound base is the only available culture option, use a swab designed for culturing aerobic and anaerobic organisms and rapidly transport it to the laboratory. (Lipsky et al.,IDSA, 2004)

...determine the type and level of infection in the debrided ulcer by tissue biopsy or by a validated quantitative swab technique. (Wound Healing Society [WHS], 2006)

[Q]uantitative culture has been shown to have high predictive value, sensitivity, and specificity. Most authors recommend the following technique for acquiring high quality wound cultures: After skin disinfection, a strip of necrotic wound tissue weighing 0.1 to 0.5 gram is excised for quantitative culture. This specimen is placed in an aerobic/anaerobic culture medium. Simultaneously, routine cotton swab is taken from the site of excision-debridement, taking care to avoid the ulcer's surface. It may occasionally be necessary to biopsy the ulcer in order to rule out [the] uncommon causes of lower extremity ulcers. (American Society of Plastic Surgeons [ASPS], 2007)

...swab specimens collected from wounds using Levine's technique performed better than swab specimens collected using either the wound exudate or Z-technique. Equally important, the findings suggest that swab specimens obtained using Levine's technique and processed using quantitative laboratory procedures are acceptably accurate when compared with the quantitative cultures of wound tissue. ...swab specimens obtained with Levine's technique will enable a wider variety of wounds to be monitored for wound bioburden than tissue cultures. In addition, Levine's technique will be much more practical for repeating cultures in suspicious wounds that produce negative findings initially than tissue cultures. (Gardner et al., 2006)

Evidence for Rationale
American Society of Plastic Surgeons, Physician Consortium for Performance Improvement®, National Committee for Quality Assurance. Chronic wound care physician performance measurement set. Chicago (IL): American Medical Association (AMA); 2010 Sep. 35 p. [19 references]

American Society of Plastic Surgeons. Evidence-based clinical practice guideline: chronic wounds of the lower extremity. Arlington Heights (IL): American Society of Plastic Surgeons; 2007 May. 21 p. [132 references]

Bamberg R, Sullivan PK, Conner-Kerr T. Diagnosis of wound infections: current culturing practices of U.S. wound care professionals. Wounds. 2002;14:314-27.

Gardner SE, Frantz RA, Saltzman CL, Hillis SL, Park H, Scherubel M. Diagnostic validity of three swab techniques for identifying chronic wound infection. Wound Repair Regen. 2006 Sep-Oct;14(5):548-57. PubMed External Web Site Policy

Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, Lefrock JL, Lew DP, Mader JT, Norden C, Tan JS. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2004 Oct 1;39(7):885-910. [290 references] PubMed External Web Site Policy

Robson MC, Cooper DM, Aslam R, Gould LJ, Harding KG, Margolis DJ, Ochs DE, Serena TE, Snyder RJ, Steed DL, Thomas DR, Wiersma-Bryant L. Guidelines for the treatment of venous ulcers. Wound Repair Regen. 2006 Nov-Dec;14(6):649-62. PubMed External Web Site Policy

Steed DL, Attinger C, Colaizzi T, Crossland M, Franz M, Harkless L, Johnson A, Moosa H, Robson M, Serena T, Sheehan P, Veves A, Wiersma-Bryant L. Guidelines for the treatment of diabetic ulcers. Wound Repair Regen. 2006 Nov;14(6):680-92. PubMed External Web Site Policy

Whitney J, Phillips L, Aslam R, Barbul A, Gottrup F, Gould L, Robson MC, Rodeheaver G, Thomas D, Stotts N. Guidelines for the treatment of pressure ulcers. Wound Repair Regen. 2006 Nov-Dec;14(6):663-79. PubMed External Web Site Policy
Primary Health Components

Chronic wound care; chronic skin ulcer; wound surface culture technique

Denominator Description

All patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Patient visits without the use of a wound surface culture technique (see the related "Numerator Inclusions/Exclusions" field)

Evidence Supporting the Measure

Type of Evidence Supporting the Criterion of Quality for the Measure
  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal
Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

Unspecified

State of Use of the Measure

State of Use
Current routine use
Current Use
Internal quality improvement
Pay-for-reporting
Professional certification
Public reporting

Application of the Measure in its Current Use

Measurement Setting
Ambulatory/Office-based Care
Professionals Involved in Delivery of Health Services
Physicians
Least Aggregated Level of Services Delivery Addressed
Individual Clinicians or Public Health Professionals
Statement of Acceptable Minimum Sample Size
Does not apply to this measure
Target Population Age

Age greater than or equal to 18 years

Target Population Gender
Either male or female

National Strategy for Quality Improvement in Health Care

National Quality Strategy Aim
Better Care
National Quality Strategy Priority
Prevention and Treatment of Leading Causes of Mortality

Institute of Medicine (IOM) National Health Care Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness

Data Collection for the Measure

Case Finding Period

Unspecified

Denominator Sampling Frame
Patients associated with provider
Denominator (Index) Event or Characteristic
Clinical Condition
Encounter
Patient/Individual (Consumer) Characteristic
Denominator Time Window
Does not apply to this measure
Denominator Inclusions/Exclusions

Inclusions
All patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer

Note: Refer to the original measure documentation for administrative codes.

Exclusions
Documentation of medical reason(s) for using a wound surface culture technique (e.g., surface culture for methicillin-resistant staphylococcus aureus (MRSA) screening)

Exclusions/Exceptions
Medical factors addressed
Numerator Inclusions/Exclusions

Inclusions
Patient visits without the use of a wound surface culture technique*

*The numerator will also be met if there is documentation that a technique other than surface culture of the wound exudate has been used to acquire the wound culture (e.g., Levine/deep swab technique, semi-quantitative or quantitative swab technique).

Note: Refer to the original measure documentation for administrative codes.

Exclusions
None

Numerator Search Strategy
Fixed time period or point in time
Data Source
Administrative clinical data
Electronic health/medical record
Paper medical record
Type of Health State
Does not apply to this measure
Instruments Used and/or Associated with the Measure

Unspecified

Computation of the Measure

Measure Specifies Disaggregation
Does not apply to this measure
Scoring
Rate/Proportion
Interpretation of Score
Desired value is a higher score
Allowance for Patient or Population Factors
Unspecified
Standard of Comparison
Internal time comparison

Identifying Information

Original Title

Measure #1: use of wound surface culture technique in patients with chronic skin ulcers (overuse measure).

Submitter
American Medical Association on behalf of the American Society of Plastic Surgeons, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance - Medical Specialty Society
Developer
American Society of Plastic Surgeons - Medical Specialty Society
National Committee for Quality Assurance - Health Care Accreditation Organization
Physician Consortium for Performance Improvement® - Clinical Specialty Collaboration
Funding Source(s)

Unspecified

Composition of the Group that Developed the Measure

Scott Endsley, MD, MSc (Co-Chair); William A. Wooden, MD, FACS (Co-Chair); Nicholas Biasotto, DO; Kathleen Lawrence, RN, MSN, CWOCN; Sergey V. Bogdan, MD; Andrew Maurano, PA-C; Stephen K. Bubb, MD; Mark Morasch, MD; H. Gunner Deery, II, MD, FACP, FIDSA; Jessica Pedersen, MBA, OTR/L, ATP; Dirk M. Elston, MD; Michael M. Priebe, MD; Elof Eriksson, MD; Aamir Siddiqui, MD; George Fueredi, MD; Carole (Carrie) Sussman, PT, DPT; Matthew G. Garoufalis, DPM; Amy Wandel, MD, FACS; Sarah Kagan, PhD, RN

American Society of Plastic Surgeons: Melanie Dolak, MHA

American Medical Association: Joseph Gave, MPH; Karen Kmetik, PhD; Shannon Sims, MD, PhD; Samantha Tierney, MPH

National Committee for Quality Assurance: Phil Renner, MBA

PCPI Consultants: Rebecca Kresowik; Timothy Kresowik, MD

Financial Disclosures/Other Potential Conflicts of Interest

Conflicts, if any, are disclosed in accordance with the Physician Consortium for Performance Improvement® conflict of interest policy.

Measure Initiative(s)
Ambulatory Care Quality Alliance (AQA)
Physician Quality Reporting System
Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC
2010 Sep
Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

The Physician Consortium for Performance Improvement reaffirmed the currency of this measure in November 2011.

Source(s)
American Society of Plastic Surgeons, Physician Consortium for Performance Improvement®, National Committee for Quality Assurance. Chronic wound care physician performance measurement set. Chicago (IL): American Medical Association (AMA); 2010 Sep. 35 p. [19 references]
Measure Availability

The individual measure, "Measure #1: Use of Wound Surface Culture Technique in Patients with Chronic Skin Ulcers (Overuse Measure)," is published in "Chronic Wound Care Physician Performance Measurement Set." This document and technical specifications are available in Portable Document Format (PDF) from the American Medical Association (AMA)-convened Physician Consortium for Performance Improvement® Web site: www.physicianconsortium.org External Web Site Policy.

For further information, please contact AMA staff by e-mail at cqi@ama-assn.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on April 7, 2009. The information was verified by the measure developer on June 4, 2009. This NQMC summary was retrofitted into the new template on May 13, 2011. The information was reaffirmed by the measure developer on November 30, 2011. This NQMC summary was edited by ECRI Institute on April 27, 2012.

Copyright Statement

© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved.

CPT® Copyright 2007 American Medical Association

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