wound classification

Wound Classification

Meredith Kopp, RNJoyce McCollum, RN

Chelsea Ford, RNChildren’s Mercy Hospitals & Clinics

Kansas City, MO

Objectives

• Define the four CDC classifications for surgical wounds.

• Identify patients at risk for surgical site infections based on preoperative wound classification.

• Describe the role of the perioperative nurse in documentation of the surgical wound class.

CMH Policy

The surgical wound classification is defaulted into each surgical procedure in the perioperative electronic record. Surgical wounds will be reviewed at the end of each procedure with adjustments as needed and recorded on the medical record by the circulating nurse.

Wounds are classified according to the likelihood and degree of wound contamination at the time of the procedure. Wound classification assignment is the joint responsibility of the surgeon and nursing staff.

Section: Infection Control / Surgery Unit-Specific Procedures

History & Alphabet Soup

• Since the landmark 1964 National Academy of Sciences’ National Research Council study on use of UV lights in the OR, wounds have been classified by the level of risk of contamination.

• CDC (Centers for Disease Control) developed Wound Class System based on criteria from ACS (American College of Surgeons) and 1964 study.


• NHSN (National Healthcare Safety Network), formerly called NNISC (National Nosocomial Infection Surveillance Committee – part of the CDC– Voluntary, internet-based data base of

patient and health care personnel safety and surveillance systems

– Analyze data and recognize trends


• Term “SSI” or “Surgical Site Infection” was created in 1992 by the CDC in collaboration with the ACS to differentiate between a surgical wound infection and a traumatic wound infection.

• Another term in use is “HAI” or “Healthcare-Associated Infection” which includes other, non-wound infections as well as SSI.

Definition of SSI

• A surgical site infection is infection developed within 30 days of a surgical procedure.

• Or 1 year following an implant procedure.

SSI Categories

Superficial Incisional SSI• Infection occurring within 30 days post-op

involving only skin or subcutaneous tissue with at least one of the following:

– Purulent drainage from the superficial incision– Positive culture from the superficial incision– At least one sign/symptom of infection and re-opened

incision– Pain/tenderness, localized swelling, redness, heat– Diagnosis of SSI made by the surgeon or attending physician

• Does not include stitch abscess, episiotomy, newborn circ infections, or burn wounds

SSI CategoriesDeep incisional SSI• Infection occurring within 30 days postop (no

implant) or within 1 year of implant• Appears to be related to the operation• Involves deep, soft tissues (fascia, muscles)• Including at least one of the following:

– Purulent drainage from deep incision (but not organ/space component)

– Spontaneous dehiscence or deliberately re-opened incision with positive culture and one or more signs or symptoms of infection (fever, localized pain/tenderness)

– Abscess or other evidence of infection by exam, culture, or Xray

– Diagnosis of deep incisional SSI is made by surgeon or physician

SSI Categories

Organ/Space SSI• Infection occurring within 30 days postop (no

implant) or within 1 year of implant and appears to be related to the operation.

• Involving any part of the anatomy other than the incision, fascia, or muscle layers involved in the surgical procedure AND at least one of the following:– Purulent drainage noted from a drain coming from the

organ/space– Positive culture from the organ or space– Abscess or other evidence of infection by exam, culture, or

Xray– Diagnosis of organ/space SSI is made by surgeon or

physician

Incidence

• Superficial incisional SSI is more common than deep incisional SSI and organ/space SSI :– accounts for more than half of all SSI’s

for all categories of surgery

• Postoperative length of stay is longer for patients with any SSI, when adjusted for other factors influencing length of stay.

NHSN Risk Index

• National Healthcare Safety Network– Developed risk index for

SSI’s including ASA class

• Patient-specific Risk Score of 0 – 3 points

• As the risk index score increased, the proportion of infected patients increased:– 27% for a risk score of

0– 100% for a risk score

of 3

Wound class III or IV

1 point

ASA class 3,4,5

1 point

Duration of surgery longer than 75th percentile for that procedure

1 point

Other National Initiatives

• ACS’s Surgical Care Improvement Project (NSQIP) Collects data on 135 variables including

preop status, intraop variables, and postop outcomes up to 30 days for major surgical procedures


• Institute for Health Care Improvement (IHI)

• 5 Million Lives campaign

• Goal: – Significantly reduce

methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection by reliably implementing five components of care

1. Hand hygiene2. Decontamination of the environment and equipment3. Active surveillance 4. Contact precautions for infected and colonized patients5. Device bundles (Central Line Bundle and Ventilator Bundle)


• Association for Professionals in Infection Control and Epidemiology (APIC)

• “Targeting Zero” Healthcare Associated Infections (HAIs)

Setting the theoretical goal of elimination of HAIs by promoting a culture of zero tolerance

CMH OR Nursing Care PlanNursing Diagnosis:Potential for Infection

Patient Outcome 010:“The patient is free from signs and symptoms of infection”

Nursing Interventions:– Skin prepped according

to surgeon preference and AORN standards

– Strict aseptic technique– Assess skin condition

preop and document– Ensure sterility, monitor

aseptic technique of team

– Record Wound Classification

Documentation

• Responsibility of the perioperative RN

• In collaboration with surgeon

• Revise documented wound class as indicated by change or extension in the procedure

Definition – Class I“Clean”

• Uninfected operative wound, no inflammation encountered

• Respiratory, Alimentary, Genital, or uninfected urinary tract is NOT entered.

• Primarily closed and if needed, drained with closed drainage device.

Examples of Clean Wound Cases

• operative wounds following blunt non-penetrating trauma

• Total hip arthroscopy

• Mitral valve replacement

• Breast biopsy

Definition – Class II

“Clean-Contaminated”• Operative wound

entering Respiratory, Alimentary, Genital, or Urinary tract under controlled conditions, without unusual contamination.

• Biliary tract, appendix, vagina, or oropharynx

• Procedures using Penrose drains

Examples of Clean – Contaminated Wound Cases

• Tonsillectomies• Cholecystectomy• Hysterectomy• Thoracotomy• Cystoscopy• “Interval”

appendectomy

Definition – Class III

“Contaminated”• Open, fresh, accidental

wounds• Operations with breaks

in sterile technique• Gross spillage from GI

tract during procedure• acute, nonpurulent

inflammation – i.e. appendectomy

for acute appendicitis

Examples of Contaminated Wound Cases

• Stab wound to chest involving lung

• Open cardiac massage

• Bile spillage• Amputation for

“dry” gangrene

Definition – Class IV“Dirty -Infected”

• Existing clinical infection

• Old traumatic wounds with retained, devitalized tissue

• Perforated viscera/appendix

• Suggests that organisms causing infection were present in operative site pre-operatively

Examples of Dirty-Infected Wound Cases

• Delayed primary closure after ruptured appy

• Myringotomy for otitis media with pus

• Excision and drainage of abscess

• Peritonitis• Amputation for “wet”

gangrene

Why it Matters

• Predictor of SSI risk

• Used to analyze quality outcomes

• National benchmarking

• Reimbursement:– “As of October 1st, 2008, The Centers for

Medicare & Medicaid Services no longer will reimburse facilities for certain hospital-acquired conditions.”

Predicting Risk of SSI

Outcomes risk = probability that a patient may have a poor outcome based on his or her preintervention condition

The higher a patient’s preintervention risk status, the greater the chance he or she will experience a poor outcome, if all other things are equal.

Risk Adjustment

• Allows outcomes to be compared fairly

• Wound class considered in many outcome studies as a predictor of SSI’s and associated risks

• Recent study of appy patients– Class III or IV predicted increased morbidity– However 18% of procedures were

misclassified, so…Study results are suspect!!

Risk for SSI

Class I

“Clean” wounds

1 -5% risk of postoperative infection

Class II

“Clean-contaminated”

5-10% risk of postoperative infection

Class III

“Contaminated”Approximately 20%risk of SSI

Class IV

“Dirty” woundsApproximately 40% risk of SSI

Issues with Wound Class Determination

Study by nurses at Mass. General found 19% misclassification rate

• Contributing factors:– automatic defaults in the electronic record– Lack of communication between surgeons

and nurses regarding unexpected findings or change in technique

– Admitted lack of understanding of the correct class or need to change the default entry

Degree of Bacterial Load

• Wound contamination - the presence of bacteria within a wound without any host reaction

• Wound colonisation - the presence of bacteria within the wound which do multiply or initiate a host reaction

• Critical colonisation - multiplication of bacteria causing a delay in wound healing, usually associated with an exacerbation of pain not previously reported but still with no overt host reaction

• Wound infection - the deposition and multiplication of bacteria in tissue with an associated host reaction

Gray areas

• CDC does not specifically address:• Pediatric patients• Out-of-OR procedures• Surgical wounds unique to minimally

invasive procedures• No clear definition of “major break” in

aseptic technique

• Clinical judgement needed; ultimate decision should be made by surgeon

Examples

Wounds with a Penrose or rubber band drain Class II

Cystoscopy Class II

Diagnostic Laparoscopy with use of uterine manipulator

Class II

Bronchoscopy Class II

Thyroidectomy Class I

Thyroglossal Duct Cyst Class II

Examples from CMH

Service: PlasticsPre-op Diagnosis:

Dog bite multiple lacerations

Procedure: I&D

Cerner Default: Clean-contaminated

Operative Report: Severe dog attack trauma, multiple open wounds, extensive washout

CORRECT WOUND CLASS = DIRTY/INFECTED

Examples from CMH

Service: Ortho

Diagnosis: Traumatic amputation of fingertip from crushing rock

Procedure: Revision of amputation stump, debridement

Cerner default: Clean

Op Report: Resected exposed bone, washout, imbedded dirt


Examples from CMH

Service: Neurosurgery

Diagnosis: Meningitis, suspected CSF Shunt Infection

Procedure: Removal of shunt, place Lumbar Drain

Cerner default: Clean

Op Report: Contaminated shunt, external drain post-op


Examples from CMH

Service: ENT

Diagnosis: RAOM, CSOM

Procedure: BMT, Adenoidectomy

Cerner default: Clean-contaminated

Op report: “There were ear infections bilaterally today…copious purulence from nose and airway”


Examples from CMHService: EYE &

Plastics comboDiagnosis: Lesions on

eyelid, face, scalp, tongue

Pre-op: “multiple crusted lesions”

Common Misclassifications

• Appendectomy, Laparoscopic or open

• Cholecystectomy, Laparoscopic or openClean-Contaminated is default BUT:

• If inflammation from acute appendicitis is present, Wound Class is CONTAMINATED

• If perforation / purulence found, Wound Class is DIRTY/INFECTED

• If bile spillage occurs, Wound Class is CONTAMINATED

wound classification

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