promoting excellence in surgical wound classification

Promoting Excellence in Surgical Wound Classification

Alix Kite, Clinical Nurse Educator, Operating Room, Peace Arch Hospital,

Laura Holmes, Surgical Clinical Reviewer, Peace Arch Hospital,

Susann Camus, Quality Improvement Consultant, FH NSQIP

November 16, 2012

Background

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

• NSQIP introduced at PAH in July/11o Surgical Clinical Reviewer

immediately identified discrepancies in wound class

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

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- Increase accuracy of surgical wound classification at PAH to 100%- Promote overall team communication within the OR - Increase positive surgical outcomes for patients

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Team goals

• Predictor of postsurgical site infection

• Risk adjusted data will make your site look better/worse than it really is

• Drives quality improvement initiatives

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Why wound class is important

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Risk of developing a postsurgical infection

Wound Classification

•Snapshot of the operative wound•Predicts risk of postoperative

infection based on assessment of bacterial load at time of surgery

•Assists surgeon determine his/her approach to postop care

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Wound Class I: Clean• Respiratory, gastrointestinal,

genital and urinary tracts not entered

•No break in aseptic technique

•No inflammation

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Wound Class 1: Examples

• Breast surgery• C-section with non-ruptured

membranes• Exploratory lap with no bowel

resection• Eye Surgery (unless inflamed,

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

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Wound Class II: Clean-Contaminated• Respiratory, gastrointestinal, genital,

or urinary tract is entered under controlled conditions

• No major break in aseptic technique

• No acute inflammation• No spillage

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Wound Class II: Examples

• Cholecystectomy (chronic inflammation)

• Gastrointestinal procedures• Gynecological procedures• Urological procedures

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Wound Class III: Contaminated• Acute, nonpurulent inflammation

is encountered• Open, fresh, accidental wounds • Operations with major breaks in

sterile technique• Visible spillage from intestinal tract• Necrotic tissue without evidence of

purulent drainage

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Wound Class III: Examples

• 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

• Presence of purulence or abscess • Perforated viscera• Fecal contamination• Traumatic wounds with retained

devitalized (dying) tissue• Wet gangrene

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16 November 2012 Surgical Wound Classification

Wound Class IV: Examples

• 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 ulcer

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How and when to document wound class• At the end of the surgical

procedure at the time of the Surgical Checklist Debriefing

• Why at the end: Capture any events that occurred during the surgery that may influence wound class (Zinn, 2012)

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Establishing your Wound Class Plan

• Understand why wounds are misclassified• Promote communications on accurate wound

classification• Do ongoing Perioperative Nursing Record

reviews for education purposes• Do targeted education (e.g. appendectomies)• Monitor data for improvement• Communicate results (emails, posters)• Celebrate milestones and successes

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• Jennifer Zinn of Cone Health• NSQIP & BC Patient Safety & Quality Council• FH’s Operating Room Clinical Nurse Educators • FH’s Surgical Clinical Reviewers

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Thanks to…

Questions?

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