Wound Classification

1. Wound Classification Meredith Kopp, RN Joyce McCollum, RN Chelsea Ford, RN Children’s Mercy Hospitals & Clinics Kansas City, MO

2. Objectives • Define the four CDC classifications for surgical wounds. • Identify patients at risk for surgical site infections based on preoperative wound classification. • Describe the role of the perioperative nurse in documentation of the surgical wound class.

3. CMH Policy The surgical wound classification is defaulted into each surgical procedure in the perioperative electronic record. Surgical wounds will be reviewed at the end of each procedure with adjustments as needed and recorded on the medical record by the circulating nurse. Wounds are classified according to the likelihood and degree of wound contamination at the time of the procedure. Wound classification assignment is the joint responsibility of the surgeon and nursing staff. Section: Infection Control / Surgery Unit-Specific Procedures

4. History & Alphabet Soup • Since the landmark 1964 National Academy of Sciences’ National ResearchCouncil study on use of UV lights in the OR, wounds have been classified by the level of risk of contamination. • CDC (Centers for Disease Control) developed Wound Class System based on criteria from ACS (American College of Surgeons) and 1964 study.

5. History & Alphabet Soup • NHSN (National Healthcare Safety Network), formerly called NNISC (National Nosocomial Infection Surveillance Committee – part of the CDC • Voluntary, internet-based data base of patient and health care personnel safety and surveillance systems • Analyze data and recognize trends

6. History & Alphabet Soup • Term “SSI” or “Surgical Site Infection” was created in 1992 by the CDC in collaboration with the ACS to differentiate between a surgical wound infection and a traumatic wound infection. • Another term in use is “HAI” or “Healthcare-Associated Infection” which includes other, non-wound infections as well as SSI.

7. Definition of SSI • A surgical site infection is infection developed within 30 days of a surgical procedure. • Or 1 year following an implant procedure.

8. SSI Categories Superficial Incisional SSI • Infection occurring within 30 days post-op involving only skin or subcutaneous tissue with at least one of the following: • Purulent drainage from the superficial incision • Positive culture from the superficial incision • At least one sign/symptom of infection and re-opened incision • Pain/tenderness, localized swelling, redness, heat • Diagnosis of SSI made by the surgeon or attending physician • Does not include stitch abscess, episiotomy, newborn circ infections, or burn wounds

9. SSI Categories Deep incisional SSI • Infection occurring within 30 days postop (no implant) or within 1 year of implant • Appears to be related to the operation • Involves deep, soft tissues (fascia, muscles) • Including at least one of the following: • Purulent drainage from deep incision (but not organ/space component) • Spontaneous dehiscence or deliberately re-opened incision with positive culture and one or more signs or symptoms of infection (fever, localized pain/tenderness) • Abscess or other evidence of infection by exam, culture, or Xray • Diagnosis of deep incisional SSI is made by surgeon or physician

10. SSI Categories Organ/Space SSI • Infection occurring within 30 days postop (no implant) or within 1 year of implant and appears to be related to the operation. • Involving any part of the anatomy other than the incision, fascia, or muscle layers involved in the surgical procedure AND at least one of the following: • Purulent drainage noted from a drain coming from the organ/space • Positive culture from the organ or space • Abscess or other evidence of infection by exam, culture, or Xray • Diagnosis of organ/space SSI is made by surgeon or physician

11. Incidence • Superficial incisional SSI is more common than deep incisional SSI and organ/space SSI : • accounts for more than half of all SSI’s for all categories of surgery • Postoperative length of stay is longer for patients with any SSI, when adjusted for other factors influencing length of stay.

12. NHSN Risk Index • National Healthcare Safety Network • Developed risk index for SSI’s including ASA class • Patient-specific Risk Score of 0 – 3 points • As the risk index score increased, the proportion of infected patients increased: • 27% for a risk score of 0 • 100% for a risk score of 3

13. Other National Initiatives • ACS’s Surgical Care Improvement Project (NSQIP) Collects data on 135 variables including preop status, intraop variables, and postop outcomes up to 30 days for major surgical procedures

14. Other National Initiatives • Institute for Health Care Improvement (IHI) • 5 Million Lives campaign • Goal: • Significantly reduce methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection by reliably implementing five components of care 1. Hand hygiene 2. Decontamination of the environment and equipment 3. Active surveillance 4. Contact precautions for infected and colonized patients 5. Device bundles (Central Line Bundle and Ventilator Bundle)

15. Other National Initiatives • Association for Professionals in Infection Control and Epidemiology (APIC) • “Targeting Zero” Healthcare Associated Infections (HAIs) Setting the theoretical goal of elimination of HAIs by promoting a culture of zero tolerance

16. Nursing Diagnosis: Potential for Infection Patient Outcome 010: “The patient is free from signs and symptoms of infection” Nursing Interventions: Skin prepped according to surgeon preference and AORN standards Strict aseptic technique Assess skin condition preop and document Ensure sterility, monitor aseptic technique of team Record Wound Classification CMH OR Nursing Care Plan

17. Documentation • Responsibility of the perioperative RN • In collaboration with surgeon • Revise documented wound class as indicated by change or extension in the procedure

18. Definition – Class I “Clean” • Uninfected operative wound, no inflammation encountered • Respiratory, Alimentary, Genital, or uninfected urinary tract is NOT entered. • Primarily closed and if needed, drained with closed drainage device.

19. Examples of Clean Wound Cases • operative wounds following blunt non-penetrating trauma • Total hip arthroscopy • Mitral valve replacement • Breast biopsy

20. Definition – Class II “Clean-Contaminated” • Operative wound entering Respiratory, Alimentary, Genital, or Urinary tract under controlled conditions, without unusual contamination. • Biliary tract, appendix, vagina, or oropharynx • Procedures using Penrose drains

21. Examples of Clean – Contaminated Wound Cases • Tonsillectomies • Cholecystectomy • Hysterectomy • Thoracotomy • Cystoscopy • “Interval” appendectomy

22. Definition – Class III “Contaminated” • Open, fresh, accidental wounds • Operations with breaks in sterile technique • Gross spillage from GI tract during procedure • acute, nonpurulent inflammation • i.e. appendectomy for acute appendicitis

23. Examples of Contaminated Wound Cases • Stab wound to chest involving lung • Open cardiac massage • Bile spillage • Amputation for “dry” gangrene

24. Definition – Class IV “Dirty -Infected” • Existing clinical infection • Old traumatic wounds with retained, devitalized tissue • Perforated viscera/appendix • Suggests that organisms causing infection were present in operative site pre-operatively

25. Examples of Dirty-Infected Wound Cases • Delayed primary closure after ruptured appy • Myringotomy for otitis media with pus • Excision and drainage of abscess • Peritonitis • Amputation for “wet” gangrene

26. Why it Matters • Predictor of SSI risk • Used to analyze quality outcomes • National benchmarking • Reimbursement: • “As of October 1st, 2008, The Centers for Medicare & Medicaid Services no longer will reimburse facilities for certain hospital-acquired conditions.”

27. Predicting Risk of SSI Outcomes risk = probability that a patient may have a poor outcome based on his or her preintervention condition The higher a patient’s preintervention risk status, the greater the chance he or she will experience a poor outcome, if all other things are equal.

28. Risk Adjustment • Allows outcomes to be compared fairly • Wound class considered in many outcome studies as a predictor of SSI’s and associated risks • Recent study of appy patients • Class III or IV predicted increased morbidity • However 18% of procedures were misclassified, so…Study results are suspect!!

29. Risk for SSI

30. Issues with Wound Class Determination Study by nurses at Mass. General found 19% misclassification rate • Contributing factors: • automatic defaults in the electronic record • Lack of communication between surgeons and nurses regarding unexpected findings or change in technique • Admitted lack of understanding of the correct class or need to change the default entry

31. Degree of Bacterial Load • Wound contamination - the presence of bacteria within a wound without any host reaction • Wound colonisation - the presence of bacteria within the wound which do multiply or initiate a host reaction • Critical colonisation - multiplication of bacteria causing a delay in wound healing, usually associated with an exacerbation of pain not previously reported but still with no overt host reaction • Wound infection - the deposition and multiplication of bacteria in tissue with an associated host reaction

32. Gray areas • CDC does not specifically address: • Pediatric patients • Out-of-OR procedures • Surgical wounds unique to minimally invasive procedures • No clear definition of “major break” in aseptic technique • Clinical judgement needed; ultimate decision should be made by surgeon

33. Examples

34. Examples from CMH Service: Plastics Pre-op Diagnosis: Dog bite multiple lacerations Procedure: I&D Cerner Default: Clean-contaminated Operative Report: Severe dog attack trauma, multiple open wounds, extensive washout CORRECT WOUND CLASS = DIRTY/INFECTED

35. Examples from CMH CORRECT WOUND CLASS = DIRTY/INFECTED Service: Ortho Diagnosis: Traumatic amputation of fingertip from crushing rock Procedure: Revision of amputation stump, debridement Cerner default: Clean Op Report: Resected exposed bone, washout, imbedded dirt

36. Examples from CMH Service: Neurosurgery Diagnosis: Meningitis, suspected CSF Shunt Infection Procedure: Removal of shunt, place Lumbar Drain Cerner default: Clean Op Report: Contaminated shunt, external drain post-op CORRECT WOUND CLASS = DIRTY/INFECTED

37. Examples from CMH Service: ENT Diagnosis: RAOM, CSOM Procedure: BMT, Adenoidectomy Cerner default: Clean-contaminated Op report: “There were ear infections bilaterally today…copious purulence from nose and airway” CORRECT WOUND CLASS = DIRTY/INFECTED

38. Examples from CMH Service: EYE & Plastics combo Diagnosis: Lesions on eyelid, face, scalp, tongue Pre-op: “multiple crusted lesions”

39. Common Misclassifications • Appendectomy, Laparoscopic or open • Cholecystectomy, Laparoscopic or open Clean-Contaminated is default BUT: • If inflammation from acute appendicitis is present, Wound Class is CONTAMINATED • If perforation / purulence found, Wound Class is DIRTY/INFECTED • If bile spillage occurs, Wound Class is CONTAMINATED