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/11 o 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 16 November 2012Surgical Wound ClassificationPage 1

- Increase accuracy of surgical wound classification at PAH to 100% - Promote overall team communication within the OR - Increase positive surgical outcomes for patients Page 216 November 2012Surgical Wound Classification 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 Page 316 November 2012Surgical Wound Classification Why wound class is important

16 November 2012Surgical Wound ClassificationPage 4 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 Page 516 November 2012Surgical Wound Classification

16 November 2012Surgical Wound Classification Wound Class I: Clean Respiratory, gastrointestinal, genital and urinary tracts not entered No break in aseptic technique No inflammation Page 6

16 November 2012Surgical Wound Classification 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 Page 7

16 November 2012Surgical Wound Classification 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 Page 8

16 November 2012Surgical Wound Classification Wound Class II: Examples Cholecystectomy (chronic inflammation) Gastrointestinal procedures Gynecological procedures Urological procedures Page 9

16 November 2012Surgical Wound Classification 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 Page 10

16 November 2012Surgical Wound Classification 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 Page 11

16 November 2012Surgical Wound Classification Wound Class IV: Dirty/Infected Presence of purulence or abscess Perforated viscera Fecal contamination Traumatic wounds with retained devitalized (dying) tissue Wet gangrene Page 12

16 November 2012Surgical 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 Page 13

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16 November 2012Surgical Wound Classification 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) Page 17

16 November 2012Surgical Wound Classification 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 ( s, posters) Celebrate milestones and successes Page 18

16 November 2012Surgical Wound Classification Jennifer Zinn of Cone Health NSQIP & BC Patient Safety & Quality Council FH’s Operating Room Clinical Nurse Educators FH’s Surgical Clinical Reviewers Page 19 Thanks to…

Questions? 16 November 2012Surgical Wound ClassificationPage 20