promoting excellence in surgical wound classification alix kite, clinical nurse educator, operating...
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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
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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
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• 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
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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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16 November 2012 Surgical Wound Classification
Wound Class I: Clean• Respiratory, gastrointestinal,
genital and urinary tracts not entered
•No break in aseptic technique
•No inflammation
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16 November 2012 Surgical 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
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16 November 2012 Surgical 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
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16 November 2012 Surgical Wound Classification
Wound Class II: Examples
• Cholecystectomy (chronic inflammation)
• Gastrointestinal procedures• Gynecological procedures• Urological procedures
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16 November 2012 Surgical 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
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16 November 2012 Surgical 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
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16 November 2012 Surgical 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
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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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16 November 2012 Surgical 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)
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16 November 2012 Surgical 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 (emails, posters)• Celebrate milestones and successes
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16 November 2012 Surgical 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
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Thanks to…
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Questions?
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