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Promoting Excellence in Surgical Wound Classification

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.

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Promoting Excellence in Surgical Wound Classification

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  1. 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

  2. Background • Surgical Checklist trial underway in April, May and June/11 at PAH • NSQIP introduced at PAH in July/11 • Surgical Clinical Reviewer immediately identified discrepancies in wound class • Chief of Surgery and OR CNE added wound class to Surgical Checklist debriefing in Sep/11 Surgical Wound Classification Page 1

  3. Team goals • Increase accuracy of surgical wound classification at PAH to 100% • Promote overall team communication within the OR • Increase positive surgical outcomes for patients Surgical Wound Classification Page 2

  4. Why wound class is important • Predictor of postsurgical site infection • Risk adjusted data will make your site look better/worse than it really is • Drives quality improvement initiatives Surgical Wound Classification Page 3

  5. Risk of developing a postsurgical infection Surgical Wound Classification Page 4

  6. 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 Surgical Wound Classification Page 5

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

  8. 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 Surgical Wound Classification Page 7

  9. 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 Surgical Wound Classification Page 8

  10. Wound Class II: Examples • Cholecystectomy (chronic inflammation) • Gastrointestinal procedures • Gynecological procedures • Urological procedures Surgical Wound Classification Page 9

  11. 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 Surgical Wound Classification Page 10

  12. Wound Class III: Examples • Appendectomy (inflamed, no rupture, no pus) • Bowel resection for infarcted and/or necrotic bowel • Cholecystectomy with acute inflammation orbile spillage • Compromised integrity of sterile field Surgical Wound Classification Page 11

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

  14. 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 Surgical Wound Classification Page 13

  15. Surgical Wound Classification Page 14

  16. Surgical Wound Classification Page 15

  17. Surgical Wound Classification Page 16

  18. 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) Surgical Wound Classification Page 17

  19. 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 Surgical Wound Classification Page 18

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

  21. Questions? Surgical Wound Classification Page 20

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