Promoting Excellence in Surgical Wound Classification at Peace Arch Hospital

Susann Camus Laura Holmes Dr. John Hwang Alexandra Kite

Background

• Surgical Checklist trial underway in April, May, and June/11 at PAH

• NSQIP introduced at PAH in Jul/11

– Surgical Clinical Reviewer immediately identifies discrepancies in wound class

• Chief of Surgery and OR CNE add wound class to Surgical Checklist debriefing in Sep/11

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Team goals

• Increase accuracy of surgical wound classification at PAH to 100%

• Promote team communicationswithin the Operating Room

• Increase positive surgicaloutcomes for patients

Remind me again. Which leg are we operating on?

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Why wound class (WC) is important

• Wound class (WC) is a predictor of surgical site infection (SSI) rates

• Wound class (WC) influences the surgeon’s antibiotic prescribing practices

• SSI rates drive quality improvement initiatives

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Risk of developing a surgical site infection (SSI)

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Wound classification: What is it?

• Snapshot of the operative wound

• Predicts risk of postoperative infection based on assessment of bacterial load at t ime of surgery

Dr. Joseph Lister

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Wound Class I: Wound starts as clean

• Respiratory, gastrointestinal, genital and urinary tracts not entered

• No break in aseptic technique

• No inflammation

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Wound Class I: Examples

• Breast surgery• Exploratory lap with no bowel

resection• Eye Surgery (unless inflamed,

infected, or with foreign body)• Eye Hernia repair• Total joint arthroplasty

Hip arthroplasty

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Wound Class II: Wound starts out as Clean-Contaminated

• Respiratory, gastrointestinal, genital, or urinary tract is entered under controlled condit ions

• No major break in aseptic technique

• No acute inflammation• No spil lage

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Wound Class II: Examples of Clean Contaminated Wounds

• Cholecystectomy (with chronic inflammation)

• Gastrointestinal procedures• Gynecological procedures• Urological procedures

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Wound Class III: Contaminated Wounds

• Acute, nonpurulent inflammation is encountered• Open, fresh, accidental wounds <12 hrs• Operations with major breaks in sterile technique• Visible spillage from intestinal tract

• Necrotic tissue without evidence of nonpurulent drainage (e.g. dry gangrene)

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Wound Class III: Examples of Contaminated Wounds

• Appendectomy (inflamed, no rupture, no pus)• Bowel resection for infarcted and/or necrotic bowel• Cholecystectomy with acute inflammation

or bile spillage

• Compromised integrity of sterile field

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Wound Class IV: Dirty/Infected Wounds

• Presence of purulence or abscess • Perforated viscera• Fecal contamination• Traumatic wounds with delayed treatment• Debridement of retained devitalized (dying) tissue• Wet gangrene

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Wound Class IV: Examples of Dirty/Infected Wounds

• Amputation in the presence of infection

• Exploratory lap for intra-abdominal abscess

• Incision & drainage for infection or abscess

• Ruptured appendix

• Ruptured bowel with or without fecal contamination

• Ruptured gastric ulcerPromoting Excellence in Surgical Wound Classification at Peace Arch Hospital 14March 1, 2013

Wound Class Audit of 1,018 cases

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Errors in Wound Classification

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Wound Classification Errors in General Surgery

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Establishing your Wound Class Plan• Understand that surgery has two starting points: Wound

Class I, Clean, or Wound Class II, Clean-Contaminated• Promote communications in OR on accurate wound

classification through team debriefings• Do ongoing Perioperative Nursing Record reviews for

education purposes• Do targeted education for wounds that are frequently

misclassified (e.g. appendectomies and cholecystectomies)

• Monitor data for improvement• Communicate & celebrate results

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Thanks to…

• Jennifer Zinn of Cone Health

• FH’s Operating Room Clinical Nurse Educators

• FH’s Surgical Clinical Reviewers

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