All Surgical Specialty Wound Class Review & Quiz Bruce Ryon, RN, MS, PhD Director, Performance Excellence National Surgical Quality Improvement Program bruce.r.ryon@kp.org

Wound Class Review Defined by the American College of Surgeons Largely related to bacteria presence & activity 2

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

Wound Class Review Defined by the CDC #1 - Clean 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 4

Wound Class Review Defined by the CDC #1 - Clean 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 5

Wound Class Review Defined by the CDC #1 - Clean 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 6

Wound Class Review Defined by the CDC #1 - Clean 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

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

Wound Class Simplified HIGHEST WOUND CLASS ASSIGNED TO ALL PROCEDURES USING SAME INCISION Clean Surgical Incision Site 1-11% wound infection risk Non-Tract* 1 Tract** 2 Potential or Pre-Infection 10-17% wound infection risk 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 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)

Wound Class Quiz 1st Slide – Kaiser San Francisco cases 2nd Slide 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 2nd Slide Shows the answer in multiple asterisks Note on key or important criteria

General Surgery

What is the wound class? 1.Clean 2.Clean/contaminated * 3.Contaminated 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

What is the wound class? 1.Clean ******* 2.Clean/contaminated ******* 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

What is the wound class? 1.Clean 2.Clean/contaminated * 3.Contaminated 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

What is the wound class? 1.Clean ******* 2.Clean/contaminated ******* 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

What is the wound class? 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? 1.Clean 2.Clean/contaminated 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

What is the wound class? 1.Clean 2.Clean/contaminated * 3.Contaminated 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

What is the wound class? 1.Clean ******* 2.Clean/contaminated ******* 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

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

What is the wound class? * 1.Clean 2.Clean/contaminated 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

What is the wound class? 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? 1.Clean 2.Clean/contaminated 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

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

What is the wound class? 1.Clean * 2.Clean/contaminated 3.Contaminated 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

What is the wound class? 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? 1.Clean 2.Clean/contaminated 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

What is the wound class? 1.Clean * 2.Clean/contaminated 3.Contaminated 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

What is the wound class? ******* 1.Clean ******* 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

What is the wound class? 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? 1.Clean ******* 2.Clean/contaminated ******* 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

Vascular Surgery

What is the wound class? 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? ******* 1.Clean ******** 2.Clean/contaminated 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

What is the wound class? 1.Clean 2.Clean/contaminated * 3.Contaminated 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

What is the wound class? 1.Clean 2.Clean/contaminated * 3.Contaminated 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

Orthopedics

What is the wound class? 1.Clean * 2.Clean/contaminated 3.Contaminated 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

What is the wound class? ******* 1.Clean ******** 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

What is the wound class? 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? 1.Clean 2.Clean/contaminated * 3.Contaminated 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

What is the wound class? 1.Clean 2.Clean/contaminated 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

What is the wound class? 1.Clean * 2.Clean/contaminated 3.Contaminated 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

What is the wound class? 1.Clean * 2.Clean/contaminated 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

What is the wound class? 1.Clean * 2.Clean/contaminated 3.Contaminated 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

What is the wound class? 1.Clean * 2.Clean/contaminated 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.

OB/GYN

What is the wound class? * 1.Clean 2.Clean/contaminated 3.Contaminated Laparoscopic total abdominal hysterectomy. * 1.Clean 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

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

What is the wound class? 1.Clean 2.Clean/contaminated * 3.Contaminated 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

What is the wound class? 1.Clean ******* 2.Clean/contaminated ******* 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

What is the wound class? * 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? ******* 1.Clean ******* 2.Clean/contaminated 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

What is the wound class? * 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? * 1.Clean 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

What is the wound class? 1.Clean 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

What is the wound class? 1.Clean 3.Contaminated 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

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

What is the wound class? ******* 1.Clean ******* 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

What is the wound class? * 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? 3.Contaminated 4.Dirty/Infected 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

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

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

Urology

What is the wound class? * 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? * 1.Clean 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

What is the wound class? * 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? * 1.Clean 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

What is the wound class? * 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? * 1.Clean 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

What is the wound class? * 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? * 1.Clean 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

What is the wound class? 1.Clean * 2.Clean/contaminated 3.Contaminated 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

What is the wound class? 1.Clean ******* 2.Clean/contaminated ******** 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

Head and Neck

What is the wound class? 1.Clean * 2.Clean/contaminated 3.Contaminated 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

What is the wound class? ******* 1.Clean ******* 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

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

What is the wound class? 1.Clean * 2.Clean/contaminated 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.

What is the wound class? 1.Clean * 2.Clean/contaminated 3.Contaminated Patient underwent thyroplasty with medialization for vocal cord paralysis. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

What is the wound class? ******* 1.Clean ********* 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

What is the wound class? 1.Clean 2.Clean/contaminated * 3.Contaminated 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

What is the wound class? 1.Clean ******* 2.Clean/contaminated ******* 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

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

What is the wound class? * 1.Clean 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

Plastics

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

What is the wound class? ******* 1.Clean ******* 2.Clean/contaminated 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

What is the wound class? 1.Clean * 2.Clean/contaminated 3.Contaminated 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

What is the wound class? ******* 1.Clean ******* 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

What is the wound class? 1.Clean * 2.Clean/contaminated 3.Contaminated 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

What is the wound class? 1.Clean ******* 2.Clean/contaminated ******* 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

What is the wound class? 1.Clean * 2.Clean/contaminated 3.Contaminated 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

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

What is the wound class? 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? 1.Clean * 2.Clean/contaminated 3.Contaminated 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

What is the wound class? ******* 1.Clean ******* 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.

Ophthalmology

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

What is the wound class? ******* 1.Clean ******* 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

Cardiac Vascular and Thoracic

What is the wound class? 1.Clean * 2.Clean/contaminated 3.Contaminated 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

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

What is the wound class? 1.Clean * 2.Clean/contaminated 3.Contaminated 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

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

What is the wound class? * 1.Clean 2.Clean/contaminated 3.Contaminated 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

What is the wound class? * 1.Clean 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

All Surgical Specialty Wound Class Review & Quiz Bruce Ryon, RN, MS, PhD Director, Performance Excellence National Surgical Quality Improvement Program bruce.r.ryon@kp.org