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.

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)

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

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)

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

Unspecified

Unspecified

Age greater than or equal to 18 years

Unspecified

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)

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

Unspecified

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

Unspecified

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

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

This measure was not adapted from another source.

Unspecified

Unspecified

This is the current release of the measure.

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

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 .

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

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.

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

CPT® Copyright 2007 American Medical Association