DECREASING WOUND CLASS DISCREPANCIES: A
Multidisciplinary ApproachMaineGeneral Medical CenterAugusta & Waterville, Maine
Shel Sherman, RN, MSHSASurgical Quality Specialist
Discrepancies – why care?
• Wound class III and IV are positively associated with Surgical Site Infection in many of the ACS NSQIP Risk‐Adjusted Models.
GEN Surgery SSI Risk‐Adjusted Model 1/11 – 12/11Wound class Clean/Contaminated vs. Clean: 1.018 Odds RatioWound class Contaminated vs. Clean: 1.248 Odds Ratio
• External reporting: Wound class is a required element of Inpatient Quality Reporting of SSI for colon surgery and abdominal hysterectomy.
The basics
• Decided which wound class definitions to be used in the OR.‐ ACS/CDC vs. AORN‐ Reviewed with Surgeon Champion, OR Manager, Infection Control Committee
• Definitions distributed to surgeons and nurses.• OR wound class tools modified, and eventually redesigned.• Majority of education conducted by OR Manager
Be creative
• Developed framework for ongoing collaboration between Quality department and OR leadership.
• Discrepancies compiled and graphed by SCR‐ Reviewed by OR Manager at OR staff meeting.‐ Standing agenda item reviewed by SCR at multidisciplinary committee: surgeons, OR staff, OR leadership, surgeon champion, anesthesia, & quality.
• Jeopardy‐style inservice presented by the SCR to the OR staff.
Committee discussions
Procedure RN chart
Op Note Dictation Comments
decortication, empyemectomy II IV empyema with pus = class IVmiddle ear exploration II I ear is cleangastric band & port removal II I stomach not enteredcholecystectomy, scheduled II III significantly inflamed, acute cholecystitislaparoscopic sigmoid colectomy II III acute diverticulitis with inflammationradical cystectomy, ileal conduit III II no inflammation noted, no open woundtonsillectomy III II chronic tonsillitis specified
Keep it fresh
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Wound Class Discrepancies
Target Combined Rate
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Wound Class Discrepancies
Target Combined Rate
New nursesNew surgeonsNew procedures
• At the 2 year mark, when discrepancies steadily on the rise:‐ Revised wound class flowchart.‐ Revisited Jeopardy‐style inservices: > 50% new attendees.‐ Memos from the SCR to the RN for each discrepancy.‐ Added wound class to operative summary for MD review.
• Response – discrepancies under target, at lowest levels in 8 mos.