Surgical Wound Classification Documentation for Certified Perioperative Nurse (CNOR)

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Outline

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

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

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

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?

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(2021). Improving the accuracy of surgical wound classification documentation. AORN J, 114(6), P10-P12. https://doi.org/10.1002/aorn.13581
Cahn, J. (2021), Clinical Issues—August 2021. AORN J, 114: 183-191.
https://doi.org/10.1002/aorn.13477
Murphy, L.W. (2023). Preventing surgical site infections. AORN Journal, 117(2), 126-130.
http://doi.org/10.1002/aorn.13868
Williams, K. (2023). Guidelines in practice: Patient information management. AORN
Journal, 117(1), 52-60. http://doi.org/10.1002/aorn.13844