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  • Measure Summary
  • NQMC:004410
  • Sep 2010

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.

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]

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2016.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

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)

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

Current routine use

Current Use

Internal quality improvement

Professional certification

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 Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

Living with Illness

IOM Domain

Effectiveness

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

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

Original Title

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

Measure Collection Name

Chronic Wound Care Physician Performance Measurement Set

Submitter

American Society of Plastic Surgeons

Developer

American Society of Plastic Surgeons

National Committee for Quality Assurance

Physician Consortium for Performance Improvement®

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.

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 measure developer reaffirmed the currency of this measure in January 2016.

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

Source not available electronically.

For more information, contact the American Society of Plastic Surgeons (ASPS) at 444 E. Algonquin Rd., Arlington Heights, IL 60005; Phone: 847-228-9900; Fax: 847-709-7524; Web site: www.plasticsurgery.org External Web Site Policy.

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.

This NQMC summary was edited by ECRI Institute on April 27, 2012.

The information was reaffirmed by the measure developer on January 7, 2016.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

For more information, contact Diedra D. Gray, Senior Manager, Quality and Health Policy, at the American Society of Plastic Surgeons, 444 E. Algonquin Rd., Arlington Heights, IL 60005; Phone: 847-228-3389.

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