Surgical Wound Classification Documentation

Guidelines:

• Accurate documentation of surgical wound classification by OR nurses is one critical element in determining the risk of surgical site infections (SSIs)
• Surgical wound classification is determined via:
  • Communication among the surgical team members
  • Observation
  • Review of the health record
• Surgical wound classification documentation is a component of patient information management. The patient’s health care record is a legal document and must provide an accurate representation of care
• Documentation must adhere to local, state, and federal regulations and facility policies and may also incorporate recommendations from nation professional guidelines

Considerations:

• The wound classification for any procedure is dependent on:
  • The procedure performed
  • The presence of infection
    • Acute inflammation
    • Purulence
  • Contamination
    • major break in sterile technique

Nurse’s role:

• At the end of any procedure, the interdisciplinary team should agree on surgical wound classification.
• Perioperative RN:
  • Team communication-Debriefs with the surgical team to confirm surgical wound classification
  • Documents the surgical wound classification in the patient’s perioperative health record
  • Ensures documentation of surgical wound classification is consistent among different team members and among different patients with similar procedural characteristics
  • Utilizes decision tree to consistently and accurately determine surgical wound classification
    • AORN Surgical Wound Classification Decision Tree

Pitfalls:

• Discrepancies in the documented surgical wound classification and the actual surgical wound classification can occur due to:
  • Lack of resources
    • Education, decision tree
  • Lack of communication with the surgeons
  • Misconceptions regarding surgical wound classification documentation
    • “Dirty implies that their sterile technique is impaired
• SSIs have the largest range of annual costs of all health care-associated infections at $3.5 billion to $10 billion
• Discrepancy in surgical wound classification documentation can result in a wound being incorrectly reported as a SSI

Examples:

• No wound = No wound classification
• Clean wound = Class I
  • Not infected or inflamed
  • The result of a non-penetrating, blunt trauma
  • No entry into respiratory, alimentary, or GU tract
  • Wound primarily closed or drained with closed drainage
• Clean-Contaminated = Class II
  • Respiratory, alimentary, or GU tract entered under controlled conditions without evidence of infection or contamination or major break in technique (spillage from GI tract)
• Contaminated = Class III
  • Fresh, open, or accidental wounds
  • Gross spillage from GI tract
  • Acute non-purulent inflammation present
  • Major break in sterile technique (unsterile instruments)
• Dirty, Infected = Class IV
  • Old wound with retained devitalized tissue
    • Gangrene, necrosis
  • Existing clinical infection
    • Purulence
  • Perforated viscera
• So think about a routine laparoscopic appendectomy. The wound class depends on what the surgeon sees once they get in there. Is it inflamed? Ruptured?

Linchpins (Key Points):

• Team communication to reach agreement on surgical wound classification
• Accurate documentation of surgical wound classification
• Decision tree to facilitate surgical wound classification
• Discrepancies can lead to incorrectly reported SSIs