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All Surgical Specialty Wound Class Review & Quiz Bruce Ryon, RN, MS, PhD Director, Performance Excellence National Surgical Quality Improvement Program.

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Presentation on theme: "All Surgical Specialty Wound Class Review & Quiz Bruce Ryon, RN, MS, PhD Director, Performance Excellence National Surgical Quality Improvement Program."— Presentation transcript:

1 All Surgical Specialty Wound Class Review & Quiz Bruce Ryon, RN, MS, PhD Director, Performance Excellence National Surgical Quality Improvement Program

2 Bruce Ryon, RN, MS, PhD Wound Class Review Defined by the American College of Surgeons -Largely related to bacteria presence & activity

3 Bruce Ryon, RN, MS, PhD Wound Class Review Defined by the CDC -Largely related to bacteria presence & activity #1 - Clean -Any incision thru non-infected material NOT in major tracts

4 Bruce Ryon, RN, MS, PhD Wound Class Review Defined by the CDC -Largely related to bacteria presence & activity #1 - Clean -Any incision thru non-infected material NOT in major tracts #2 - Clean, Contaminated -Baseline in GI, respiratory, reproductive, urinary tracts

5 Bruce Ryon, RN, MS, PhD Wound Class Review Defined by the CDC -Largely related to bacteria presence & activity #1 - Clean -Any incision thru non-infected material NOT in major tracts #2 - Clean, Contaminated - Baseline in GI, respiratory, reproductive, urinary tracts #3 - Contaminated -Presence of contained acute inflammation (not chronic) -Dry, but not wet and active gangrene -Example: inflamed, non-perforated appendix

6 Bruce Ryon, RN, MS, PhD Wound Class Review Defined by the CDC -Largely related to bacteria presence & activity #1 - Clean -Any incision thru non-infected material NOT in major tracts #2 - Clean, Contaminated - Baseline in GI, respiratory, reproductive, urinary tracts #3 - Contaminated -Presence of contained inflammation -Dry, but not wet and active gangrene -Example: inflamed, non-perforated appendix #4 – Dirty/Infected -Incision into infected material -Spilled purulence or fecal material, wet gangrene -Example: perforated and inflamed appendix with presence of purulence outside of appendix

7 Bruce Ryon, RN, MS, PhD Wound Class Review Defined by the CDC -Largely related to bacteria presence & activity #1 - Clean -Any incision thru non-infected material NOT in major tracts #2 - Clean, Contaminated - Baseline in GI, respiratory, reproductive, urinary tracts #3 - Contaminated -Presence of contained inflammation -Dry, but not wet and active gangrene -Example: inflamed, non-perforated appendix #4 – Dirty/Infected -Incision into infected material -Spilled purulence or fecal material, wet gangrene -Example: perforated and inflamed appendix with presence of purulence outside of appendix

8 Baseline Procedures & Wound Class Non-tracts - 1 Orthopedics – 1 Breast – 1 Vascular – 1 Cardiovascular – 1 Plastics – 1 Hernia - 1 Tracts - 2 Head & Neck – 2 Thoracic (lung) - 2 OB/GYN – 2 Colorectal – 2 Hepatobiliary – 2 Urology – 2 Bruce Ryon, RN, MS, PhD

9 Wound Class Simplified Tract** 2 Non-Tract* 1 Acute Inflammation, dry (ischemic) gangrene, breaks in technique, spillage, true foreign bodies 3 Incision into pus, purulence, abscess, wet (infected) gangrene, old dead tissue 4 Clean Surgical Incision Site 1-11% wound infection risk Potential or Pre-Infection 10-17% wound infection risk Visually Active Infection >27% wound infection risk * Ortho, cardiac, vascular, plastics, hernia, breast, abdominal outside of tracts ** Reproductive, urinary, renal, ear, nose, throat, pulmonary, colorectal, hepatobiliary 1 & 2 includes chronic inflammation at these sites, e.g., arthritic joint (1), colitis/Crohns (2) HIGHEST WOUND CLASS ASSIGNED TO ALL PROCEDURES USING SAME INCISION

10 Bruce Ryon, RN, MS, PhD Wound Class Quiz 1 st Slide – Kaiser San Francisco cases –Scenario explained with choices –Circulator recording marked by *asterisk –Think about the baseline of the procedure –Then think about anything that would change that baseline 2 nd Slide –Shows the answer in multiple asterisks –Note on key or important criteria

11 General Surgery

12 Bruce Ryon, RN, MS, PhD What is the wound class? A patient under went a Whipple for cancer. Surgery included a cholecystectomy. Gallbladder was documented as having changes consistent with chronic cholecystitis. 1.Clean 2.Clean/contaminated * 3.Contaminated 4.Dirty/Infected

13 Bruce Ryon, RN, MS, PhD What is the wound class? A patient under went a Whipple for cancer. Surgery included a cholecystectomy. Gallbladder was documented as having changes consistent with chronic cholecystitis. 1.Clean ******* 2.Clean/contaminated ******* * 3.Contaminated 4.Dirty/Infected Note: Chronic inflammation would not bump it to a 3

14 Bruce Ryon, RN, MS, PhD What is the wound class? An 18 year old patient with extensive Crohns disease underwent a total colectomy with a colostomy. 1.Clean 2.Clean/contaminated * 3.Contaminated 4.Dirty/Infected

15 Bruce Ryon, RN, MS, PhD What is the wound class? An 18 year old patient with extensive Crohns disease underwent a total colectomy with a colostomy. 1.Clean ******* 2.Clean/contaminated ******* 3.Contaminated 4.Dirty/Infected Note: Chronic inflammation would keep it at a 2 and not bump it to a 3

16 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a breast biopsy. The operative report noted multiple areas of fatty necrosis on the large mass. There was also necrotic tissue around the mass. 1.Clean 2.Clean/contaminated 3.Contaminated * 4.Dirty/Infected

17 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a breast biopsy. The operative report noted multiple areas of fatty necrosis on the large mass. There was also necrotic tissue around the mass. 1.Clean 2.Clean/contaminated ******* 3.Contaminated ******* * 4.Dirty/Infected Note: Necrotic, ischemic dead tissue, without infection is a 3

18 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent laparoscopic appendectomy. The pre op CT scan reported the appendix contained a fecalith. There was no mention of infection, rupture or inflammation on the operative report. 1.Clean 2.Clean/contaminated * 3.Contaminated 4.Dirty/Infected

19 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent laparoscopic appendectomy. The preop CT scan reported the appendix contained a fecalith. There was no mention of infection, rupture or inflammation on the operative report. 1.Clean ******* 2.Clean/contaminated ******* * 3.Contaminated 4.Dirty/Infected Note: Fecalith contained within GI tract w/o infection or inflammation is a 2

20 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “inflamed appendix without perforation”. * 1.Clean 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

21 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “inflamed appendix without perforation”. * 1.Clean 2.Clean/contaminated ******* 3.Contaminated ******** 4.Dirty/Infected Note: Acute inflammation is a 3

22 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “inflamed appendix without perforation with exudates”. 1.Clean 2.Clean/contaminated 3.Contaminated * 4.Dirty/Infected

23 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “injected appendix without perforation with exudates”. 1.Clean 2.Clean/contaminated ******* 3.Contaminated ******* * 4.Dirty/Infected Note: Exudates outside of non-perforated injected appendix is a 3

24 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “acute appendix with perforation”. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

25 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “acute appendix with perforation”. 1.Clean * 2.Clean/contaminated 3.Contaminated ******* 4.Dirty/Infected ******* Note: Perforated appendix assumes infected contents have spilled into abdominal cavity

26 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent an exploratory laparoscopic for possible small bowel obstruction. The procedure performed was terminal ileum resection. The operative report states “necrotic cecum and appendix”. 1.Clean 2.Clean/contaminated 3.Contaminated * 4.Dirty/Infected

27 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent an exploratory laparoscopic for possible small bowel obstruction. The procedure performed was a terminal ileum resection. The operative report states surgeon found a “necrotic cecum and appendix”. 1.Clean 2.Clean/contaminated ******* 3.Contaminated ******* * 4.Dirty/Infected Note: Necrosis, ischemic dead tissue, is generally not infected

28 Bruce Ryon, RN, MS, PhD What is the wound class? With a patient in significant abdominal pain, a preop CT scan indicated patient had SBO (small bowl obstruction). An ex-lap was performed and adhesion lysis freed up a SBO. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

29 Bruce Ryon, RN, MS, PhD What is the wound class? With a patient in significant abdominal pain, a preop CT scan indicated patient had SBO (small bowl obstruction). An ex-lap was performed and adhesion lysis freed up a SBO. ******* 1.Clean ******* * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected Note: Bowel was never incised, therefore surgery is on par with hernia repair

30 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a rectopexy procedure (rectal prolapse) where a portion of the rectum was resected. The anastamosis was checked for patency/leaks by rigid sigimoidoscopy. 1.Clean 2.Clean/contaminated 3.Contaminated * 4.Dirty/Infected

31 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a rectopexy procedure (rectal prolapse) where a portion of the rectum was resected. The anastamosis was checked for patency/leaks by rigid sigimoidoscopy. 1.Clean ******* 2.Clean/contaminated ******* 3.Contaminated * 4.Dirty/Infected Note: Anal & rectum procedures are 2, unless infection present, e.g. abscess/fistula

32 Vascular Surgery

33 Bruce Ryon, RN, MS, PhD What is the wound class? Patient had necrotic foot d/t complications from peripheral ischemia r/t 150 pack years of smoking. Surgeon performed below knee amputation where the incision was clean without infection. 1.Clean 2.Clean/contaminated 3.Contaminated * 4.Dirty/Infected

34 Bruce Ryon, RN, MS, PhD What is the wound class? Patient had necrotic foot d/t complications from peripheral ischemia r/t 150 pack years of smoking. Surgeon performed below knee amputation where the incision was clean without infection. ******* 1.Clean ******** 2.Clean/contaminated 3.Contaminated * 4.Dirty/Infected Note: Incision was in a clean area, therefore on par with ortho baseline surgery

35 Bruce Ryon, RN, MS, PhD What is the wound class? Long term diabetic patient had infected gangrenous below-the-knee-amputation stump after vascular grafts failed to improve leg perfusion. Surgeon performed above the knee amputation AKA where the initial incision expressed lymphatic pus. AKA surgery successful. 1.Clean 2.Clean/contaminated * 3.Contaminated 4.Dirty/Infected

36 Bruce Ryon, RN, MS, PhD What is the wound class? Long term diabetic patient had infected gangrenous below-the-knee-amputation stump after vascular grafts failed to improve leg perfusion. Surgeon performed above the knee amputation (AKA) where the initial incision expressed lymphatic pus. AKA surgery successful. 1.Clean 2.Clean/contaminated * 3.Contaminated ******* 4.Dirty/Infected ******* Note: Incision cut into infected material

37 Bruce Ryon, RN, MS, PhD Orthopedics

38 Bruce Ryon, RN, MS, PhD What is the wound class? THA for osteoarthritis of left hip. Bone was very good with advanced wear of both surfaces. No evidence of any other disease process. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

39 Bruce Ryon, RN, MS, PhD What is the wound class? THA for osteoarthritis of left hip. Bone was very good with advanced wear of both surfaces. No evidence of any other disease process. ******* 1.Clean ******** * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected Note: Ortho cases are a baseline 1 wound class

40 Bruce Ryon, RN, MS, PhD What is the wound class? Left knee several years status post total knee arthroplasty with rotating platform, status post arthroscopy with aspirate confirming coagulase negative staphylococcal infection. 1.Clean 2.Clean/contaminated 3.Contaminated * 4.Dirty/Infected

41 Bruce Ryon, RN, MS, PhD What is the wound class? Left knee several years status post total knee arthroplasty with rotating platform, status post arthroscopy with aspirate confirming coagulase negative staphylococcal infection. 1.Clean 2.Clean/contaminated 3.Contaminated ******* 4.Dirty/Infected ******* Note: Presence of infection = 4

42 Bruce Ryon, RN, MS, PhD What is the wound class? Open left tib/fib fracture with intramedullary rod fixation, locked proximally and distally. Irrigation/debridement of devitalized tissue d/t compound fracture. 1.Clean 2.Clean/contaminated * 3.Contaminated 4.Dirty/Infected

43 Bruce Ryon, RN, MS, PhD What is the wound class? Open left tib/fib fracture with intramedullary rod fixation, locked proximally and distally. Irrigation/debridement of devitalized tissue d/t compound fracture. 1.Clean 2.Clean/contaminated ******* 3.Contaminated ******* 4.Dirty/Infected Note: Presence of devitalized (necrotic) tissue = 3

44 Bruce Ryon, RN, MS, PhD What is the wound class? Diagnostic arthroscopy, extensive washout, debridement of lateral portal. Extensive grade 3-4 arthritis in all three compartments. No evidence of intra-articular pus. The lateral portal had some soft tissue necrosis which was debrided. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

45 Bruce Ryon, RN, MS, PhD What is the wound class? Diagnostic arthroscopy, extensive washout, debridement of lateral portal. Extensive grade 3-4 arthritis in all three compartments. No evidence of intra-articular pus. The lateral portal had some soft tissue necrosis which was debrided. 1.Clean * 2.Clean/contaminated ******* 3.Contaminated ******* 4.Dirty/Infected Note: Presence of devitalized (necrotic) tissue = 3

46 Bruce Ryon, RN, MS, PhD What is the wound class? Incision and drainage of bilateral lower extremity amputation stumps with gas gangrene bilateral, but no significant collection of any pus seen on the dressings. Wound was very large and necrotic tissue was sharply debrided. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

47 Bruce Ryon, RN, MS, PhD What is the wound class? Incision and drainage of bilateral lower extremity amputation stumps with gas gangrene bilateral, but no significant collection of any pus seen. Wound was very large and necrotic tissue was sharply debrided. 1.Clean * 2.Clean/contaminated ******* 3.Contaminated ******* or ******* 4.Dirty/Infected ******* Note: Depends of type of necrosis and if gas gangrene was emanating from debrided tissue.

48 Bruce Ryon, RN, MS, PhD OB/GYN

49 Bruce Ryon, RN, MS, PhD What is the wound class? Laparoscopic total abdominal hysterectomy. * 1.Clean 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

50 Bruce Ryon, RN, MS, PhD What is the wound class? Laparoscopic total abdominal hysterectomy. * 1.Clean ******* 2.Clean/contaminated ******* 3.Contaminated 4.Dirty/Infected Note: Hysterectomies are a baseline GYN procedure = 2

51 Bruce Ryon, RN, MS, PhD What is the wound class? 19 Y female patient with undesired pregnancy at 18w underwent a D&E with IUD insertion. No unusual findings intraop. 1.Clean 2.Clean/contaminated * 3.Contaminated 4.Dirty/Infected

52 Bruce Ryon, RN, MS, PhD What is the wound class? 19 Y female patient with undesired pregnancy at 18w underwent a D&E with IUD insertion. No unusual findings intraop. 1.Clean ******* 2.Clean/contaminated ******* * 3.Contaminated 4.Dirty/Infected Note: D&E, D&C’s & IUD insertion w/o inflammation or infection are baseline = 2

53 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent lap ovarian cystectomy with lysis of adhesions (LOA) to gain clear access to ovaries. A small hemorrhagic cyst on the left ovary was evacuated. Obliteration of cul de sac consistent with stage 4 endometriosis. * 1.Clean 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

54 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent lap ovarian cystectomy with lysis of adhesions (LOA) to gain clear access to ovaries. A small hemorrhagic cyst on the left ovary which was evacuated. Obliteration of cul de sac consistent with stage 4 endometriosis. ******* 1.Clean ******* 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected Note:Cystectomy that does not incise ovarian tract = 1, LOA = 1 Cystectomy that does incise ovarian tract = 2

55 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a Cesarean section with prolonged labor (> 20 hours), ruptured over 18 hours, thick meconium, no s/sx of infection. * 1.Clean 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

56 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a Cesarean section with prolonged labor (> 20 hours), ruptured over 18 hours, thick meconium, no s/sx of infection. * 1.Clean 2.Clean/contaminated (baseline c-section) ******* 3.Contaminated ******* 4.Dirty/Infected Note: Presence of possible non-sterile material not normally a part of organ flora

57 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a Cesarean section d/t PROM and maternal temperature over 38C/100.4F, most likely due to chorioamnioitis perforation. 1.Clean * 2.Clean/contaminated (baseline c-section) 3.Contaminated 4.Dirty/Infected

58 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a Cesarean section d/t PROM and maternal temperature over 38C/100.4F, most likely due to chorioamnioitis perforation. 1.Clean * 2.Clean/contaminated (baseline c-section) 3.Contaminated ******* 4.Dirty/Infected ******* Note: Presence of infected material from chorioamnioitis perforation

59 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a lap fallopian tube ligation with Filshie clips placed with good blanching and completely encompassing the tubes. There was no bleeding on final inspection. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

60 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a lap fallopian tube ligation with Filshie clips placed with good blanching and completely encompassing the tubes. There was no bleeding on final inspection. ******* 1.Clean ******* * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected Note: the fallopian tubes were not incised or penetrated = 1

61 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a fallopian tube ligation at the end of a Cesarean section, 3 cm segments of tube ligated with two free ties of plain gut and excised on both fallopian tubes. The lumina were visible and hemostasis was noted. * 1.Clean 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

62 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a fallopian tube ligation at the end of a Cesarean section, 3 cm segments of tube ligated with two free ties of plain gut and excised on both fallopian tubes. * 1.Clean ******* 2.Clean/contaminated ******* 3.Contaminated 4.Dirty/Infected Note: the fallopian tubes were incised = 2, the c-section = 2

63 Bruce Ryon, RN, MS, PhD What is the wound class? Elderly patient underwent a colpocleisis le forte type as part of a joint general and gynecology surgery for a colovaginal fistula. Pus was found along abscess. 1.Clean 2.Clean/contaminated * 3.Contaminated 4.Dirty/Infected

64 Bruce Ryon, RN, MS, PhD What is the wound class? Elderly patient underwent a colpocleisis le forte type as part of a joint general and gynecology surgery for a colovaginal fistula. Pus was found along abscess. 1.Clean 2.Clean/contaminated * 3.Contaminated ******* 4.Dirty/Infected ******* Note: ongoing infection = 4

65 Urology

66 Bruce Ryon, RN, MS, PhD What is the wound class? The patient had a large exophytic tumor on the lower lateral portion of the right kidney. A hand port technique was used to excise the tumor and do the renorrhaphy. * 1.Clean 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

67 Bruce Ryon, RN, MS, PhD What is the wound class? The patient had a large exophytic tumor on the lower lateral portion of the right kidney. A hand port technique was used to excise the tumor and do the renorrhaphy. * 1.Clean ******* 2.Clean/contaminated ******* 3.Contaminated 4.Dirty/Infected Note: Incision into renal/urinary tract = 2

68 Bruce Ryon, RN, MS, PhD What is the wound class? The patient had a very subtle firm nodule in the left testicle as well as palpable firm mass in his abdomen that could be felt while asleep under anesthesia. A left radical orchiectomy was performed in standard fashion. * 1.Clean 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

69 Bruce Ryon, RN, MS, PhD What is the wound class? The patient had a very subtle firm nodule in the left testicle as well as palpable firm mass in his abdomen that could be felt while asleep under anesthesia. A left radical orchiectomy was performed in standard fashion. * 1.Clean ******* 2.Clean/contaminated ******* 3.Contaminated 4.Dirty/Infected Note: Incision into reproductory tract = 2

70 Bruce Ryon, RN, MS, PhD What is the wound class? The patient underwent a repeat transurethral resection of the prostate without difficulty. There was no evidence of any intravesical lesions. There was no evidence of any perforation or uncontrolled bleeding at any point. * 1.Clean 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

71 Bruce Ryon, RN, MS, PhD What is the wound class? The patient underwent a repeat transurethral resection of the prostate without difficulty. There was no evidence of any intravesical lesions. There was no evidence of any perforation or uncontrolled bleeding at any point. * 1.Clean ******* 2.Clean/contaminated ******* 3.Contaminated 4.Dirty/Infected Note: Incision into renal/urinary tract = 2

72 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a vasectomy. The portion of vas outside the body was incised. The vas was clamped between two Mosquito clamps and the portion between the clamp was severed. The vas stumps proximal and distal were cauterized. * 1.Clean 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

73 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent a vasectomy. The portion of vas outside the body was incised. The vas was clamped between two Mosquito clamps and the portion between the clamp was severed. The vas stumps proximal and distal were cauterized. * 1.Clean ******* 2.Clean/contaminated ******** 3.Contaminated 4.Dirty/Infected Note: Incision into reproductory tract = 2

74 Bruce Ryon, RN, MS, PhD What is the wound class? The patient underwent a radical spermatic cord resection for recurrent phlegmon. The phlegmon was carefully delivered from the scrotum into the operative field and gently expressed through the incision. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

75 Bruce Ryon, RN, MS, PhD What is the wound class? The patient underwent a radical spermatic cord resection for recurrent phlegmon. The phlegmon was carefully delivered from the scrotum into the operative field and gently expressed through the incision. 1.Clean ******* 2.Clean/contaminated ******** ******* 3.Contaminated ******** 4.Dirty/Infected * 2 or 3 wound class depends on if phlegmon was acute or chronic

76 Head and Neck

77 Bruce Ryon, RN, MS, PhD What is the wound class? Tympanoplasty with R posterior perforation 30%. Thick tymapnosclerosis at the anterior border of perforation extending within the perforation forward. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

78 Bruce Ryon, RN, MS, PhD What is the wound class? Tympanoplasty with R posterior perforation 30%. Thick tymapnosclerosis at the anterior border of perforation extending within the perforation forward. ******* 1.Clean ******* * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected Note: Ear drum not populated by friendly flora

79 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent myringotomy with insertion of tube for media otitis and eustachian tube dysfuntion. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

80 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent myringotomy with insertion of tube for media otitis and eustachian tube dysfuntion. 1.Clean * 2.Clean/contaminated ****** 3.Contaminated ****** 4.Dirty/Infected Note: Otitis media is an acute inflammation process.

81 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent thyroplasty with medialization for vocal cord paralysis. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

82 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent thyroplasty with medialization for vocal cord paralysis. ******* 1.Clean ********* * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected Note: Thyroid and surrounding tissue are clean tissue

83 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent nasal septoplasty w turbinate reduction and nasal closed reduction fracture without s/s of inflammation or infection. 1.Clean 2.Clean/contaminated * 3.Contaminated 4.Dirty/Infected

84 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent nasal septoplasty w turbinate reduction and nasal closed reduction fracture without s/s of inflammation or infection. 1.Clean ******* 2.Clean/contaminated ******* * 3.Contaminated 4.Dirty/Infected Note: Baseline nasal surgeries are 2

85 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent thyroglossal duct cyst excision without s/s of inflammation or infection. * 1.Clean 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

86 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent thyroglossal duct cyst excision without s/s of inflammation or infection. * 1.Clean ******* 2.Clean/contaminated ******** 3.Contaminated 4.Dirty/Infected Note: Baseline pharnyx surgeries = 2

87 Plastics

88 Bruce Ryon, RN, MS, PhD What is the wound class? Patient with excess skin and adiposity of the abdomen underwent abdominoplasty with rectus plication, in addition to bilateral medial thigh lifts. Surgery was uncomplicated. * 1.Clean 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

89 Bruce Ryon, RN, MS, PhD What is the wound class? Patient with excess skin and adiposity of the abdomen underwent abdominoplasty with rectus plication, in addition to bilateral medial thigh lifts. Surgery was uncomplicated. ******* 1.Clean ******* 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected Note: Baseline plastics procedures = 1

90 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent nail unit excision, distal phalanx shortening, and primary closure d/t lesion (nailfold melanocytic proliferation). No unusual findings during the case. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

91 Bruce Ryon, RN, MS, PhD What is the wound class? Patient underwent nail unit excision, distal phalanx shortening, and primary closure d/t lesion (nailfold melanocytic proliferation). No unusual findings during the case. ******* 1.Clean ******* * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected Note: Baseline plastics procedures = 1

92 Bruce Ryon, RN, MS, PhD What is the wound class? 15 yo patient with underwent a vaginoplasty r/t adrenal hyperplasia. Case was completed without complication. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

93 Bruce Ryon, RN, MS, PhD What is the wound class? 15 yo patient with underwent a vaginoplasty r/t adrenal hyperplasia. Case was completed without complication. 1.Clean ******* 2.Clean/contaminated ******* 3.Contaminated 4.Dirty/Infected Note: Reproductory tract surgeries = 2

94 Bruce Ryon, RN, MS, PhD What is the wound class? Debridement of surgical wound. Necrotic skin, soft tissue as well as muscle of right groin incision with lateral pockets composed of dead fat and seroma fluid. Cultures sent from the OR for aerobic and anaerobic cultures. No drains. No complications. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

95 Bruce Ryon, RN, MS, PhD What is the wound class? Debridement of surgical wound. Findings: necrotic skin, soft tissue as well as muscle of right groin incision with lateral pockets composed of dead fat and seroma fluid. Cultures sent from the OR for aerobic and anaerobic cultures. No drains. No complications. 1.Clean * 2.Clean/contaminated ******* 3.Contaminated ******* or ******* 4.Dirty/Infected ******* Note: Dry necrotic skin = 3. PostOp labs indicate tissue was infected = 4

96 Bruce Ryon, RN, MS, PhD What is the wound class? Quadriplegic patient underwent debridement and flap closure for a chronic left ischial pressure sore Stage IV with non-healing of wound Cultures of the wound have grown out multiple organisms. 1.Clean 2.Clean/contaminated 3.Contaminated * 4.Dirty/Infected

97 Bruce Ryon, RN, MS, PhD What is the wound class? Quadriplegic patient underwent debridement and flap closure for a chronic left ischial pressure sore Stage IV with non-healing of wound Cultures of the wound have grown out multiple organisms. 1.Clean 2.Clean/contaminated 3.Contaminated ******* 4.Dirty/Infected ******* Note: Infected wound = 4

98 Bruce Ryon, RN, MS, PhD What is the wound class? 30-year-old Asian female underwent scar revision by initial excision at Stage I with VAC dressing delay. She is 18 months status post chemical burn to her left upper trunk, neck and face. Previous skin grafting is noted to be extremely thick with some contracture bands along the neck. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

99 Bruce Ryon, RN, MS, PhD What is the wound class? 30-year-old Asian female underwent scar revision by initial excision at Stage I with VAC dressing delay. She is 18 months status post chemical burn to her left upper trunk, neck and face. Previous skin grafting is noted to be extremely thick with some contracture bands along the neck. ******* 1.Clean ******* * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected Note: Class 2 is reserved for baseline tracts where friendly flora is homeostatic.

100 Ophthalmology

101 Bruce Ryon, RN, MS, PhD What is the wound class? 57 year old male patient underwent cataract surgery. Case was completed without complication. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

102 Bruce Ryon, RN, MS, PhD What is the wound class? 57 year old male patient underwent cataract surgery. Case was completed without complication. ******* 1.Clean ******* * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected Note: Baseline eye surgeries = 1

103 Cardiac Vascular and Thoracic

104 Bruce Ryon, RN, MS, PhD What is the wound class? 76 year old male was with extensive CAD was brought into the OR for an internal mammary CABG procedure. There was dense pericarditis observed after the midsternotomy. Revascularization included LAD graft to LIMA and PDA was grafted with separate segment of RSVG. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

105 Bruce Ryon, RN, MS, PhD What is the wound class? 76 year old male was with extensive CAD was brought into the OR for an internal mammary CABG procedure. There was dense pericarditis observed after the midsternotomy. Revascularization included LAD graft to LIMA and PDA was grafted with separate segment of RSVG. ******* 1.Clean ******* if chronic pericarditis * 2.Clean/contaminated ******* 3.Contaminated ******* if acute pericarditis 4.Dirty/Infected

106 Bruce Ryon, RN, MS, PhD What is the wound class? Aortic valve replacement and repair of the ascending thoracic aortic aneurysm with a 32 mm Terumo tube graft was completed on a 58 year old male. The pt was transferred to the CV ICU and a transesophageal echocardiography revealed (TEE) a well-seated valve without evidence of perivalvular leak. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

107 Bruce Ryon, RN, MS, PhD What is the wound class? Aortic valve replacement and repair of the ascending thoracic aortic aneurysm with a 32 mm Terumo tube graft was completed on a 58 year old male. The pt was transferred to the CV ICU and a transesophageal echocardiography (TEE) revealed a well-seated valve without evidence of perivalvular leak. ******* 1.Clean ******* * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected Note: Baseline heart surgeries = 1

108 Bruce Ryon, RN, MS, PhD What is the wound class? A wedge resection of the right upper lobe as well as mechanical pleurodesis was performed. The apex of the right lung was abnormal with multiple microscopic blebs, but no gross bullae. * 1.Clean 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

109 Bruce Ryon, RN, MS, PhD What is the wound class? A wedge resection of the right upper lobe as well as mechanical pleurodesis was performed. The apex of the right lung was abnormal with multiple microscopic blebs, but no gross bullae. * 1.Clean ******* 2.Clean/contaminated ******** 3.Contaminated 4.Dirty/Infected Note: Baseline lung surgeries = 2

110 All Surgical Specialty Wound Class Review & Quiz Bruce Ryon, RN, MS, PhD Director, Performance Excellence National Surgical Quality Improvement Program


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