All Surgical Specialty Wound Class Review & Quiz

1. All Surgical Specialty Wound Class Review & Quiz Bruce Ryon, RN, MS, PhD Director, Performance Excellence National Surgical Quality Improvement Program bruce.r.ryon@kp.org

2. Wound Class Review • Defined by the American College of Surgeons • Largely related to bacteria presence & activity

3. Wound Class Review • Defined by the CDC • Largely related to bacteria presence & activity • #1 - Clean • Any incision thru non-infected materialNOT in major tracts

4. Wound Class Review • Defined by the CDC • Largely related to bacteria presence & activity • #1 - Clean • Any incision thru non-infected material NOT in major tracts • #2 - Clean, Contaminated • Baseline in GI, respiratory, reproductive, urinary tracts

5. Wound Class Review • Defined by the CDC • Largely related to bacteria presence & activity • #1 - Clean • Any incision thru non-infected material NOT in major tracts • #2 - Clean, Contaminated • Baseline in GI, respiratory, reproductive, urinary tracts • #3 - Contaminated • Presence of contained acute inflammation (not chronic) • Dry, but not wet and active gangrene • Example: inflamed, non-perforated appendix

6. Wound Class Review • Defined by the CDC • Largely related to bacteria presence & activity • #1 - Clean • Any incision thru non-infected material NOT in major tracts • #2 - Clean, Contaminated • Baseline in GI, respiratory, reproductive, urinary tracts • #3 - Contaminated • Presence of contained inflammation • Dry, but not wet and active gangrene • Example: inflamed, non-perforated appendix • #4 – Dirty/Infected • Incision into infected material • Spilled purulence or fecal material, wet gangrene • Example: perforated and inflamed appendix with presence of purulence outside of appendix

7. Wound Class Review • Defined by the CDC • Largely related to bacteria presence & activity • #1 - Clean • Any incision thru non-infected material NOT in major tracts • #2 - Clean, Contaminated • Baseline in GI, respiratory, reproductive, urinary tracts • #3 - Contaminated • Presence of contained inflammation • Dry, but not wet and active gangrene • Example: inflamed, non-perforated appendix • #4 – Dirty/Infected • Incision into infected material • Spilled purulence or fecal material, wet gangrene • Example: perforated and inflamed appendix with presence of purulence outside of appendix

8. Non-tracts - 1 Orthopedics – 1 Breast – 1 Vascular – 1 Cardiovascular – 1 Plastics – 1 Hernia - 1 Tracts - 2 Head & Neck – 2 Thoracic (lung) - 2 OB/GYN – 2 Colorectal – 2 Hepatobiliary – 2 Urology – 2 Baseline Procedures & Wound Class Bruce Ryon, RN, MS, PhD

9. Tract**2 Non-Tract*1 Incision into pus, purulence, abscess, wet (infected) gangrene, old dead tissue4 Wound Class Simplified HIGHEST WOUND CLASS ASSIGNED TO ALL PROCEDURES USING SAME INCISION Clean Surgical Incision Site1-11% wound infection risk Acute Inflammation, dry (ischemic) gangrene, breaks in technique, spillage, true foreign bodies3 Potential or Pre-Infection 10-17% wound infection risk Visually Active Infection>27% wound infection risk * Ortho, cardiac, vascular, plastics, hernia, breast, abdominal outside of tracts ** Reproductive, urinary, renal, ear, nose, throat, pulmonary, colorectal, hepatobiliary 1 & 2 includes chronic inflammation at these sites, e.g., arthritic joint (1), colitis/Crohns (2)

10. Wound Class Quiz • 1st Slide – Kaiser San Francisco cases • Scenario explained with choices • Circulator recording marked by *asterisk • Think about the baseline of the procedure • Then think about anything that would change that baseline • 2nd Slide • Shows the answer in multiple asterisks • Note on key or important criteria

11. General Surgery

12. What is the wound class? A patient under went a Whipple for cancer. Surgery included a cholecystectomy. Gallbladder was documented as having changes consistent with chronic cholecystitis. 1.Clean 2.Clean/contaminated * 3.Contaminated 4.Dirty/Infected

13. What is the wound class? A patient under went a Whipple for cancer. Surgery included a cholecystectomy. Gallbladder was documented as having changes consistent with chronic cholecystitis. 1.Clean ******* 2.Clean/contaminated ******* * 3.Contaminated 4.Dirty/Infected Note: Chronic inflammation would not bump it to a 3

14. What is the wound class? An 18 year old patient with extensive Crohns disease underwent a total colectomy with a colostomy. 1.Clean 2.Clean/contaminated * 3.Contaminated 4.Dirty/Infected

15. What is the wound class? An 18 year old patient with extensive Crohns disease underwent a total colectomy with a colostomy. 1.Clean ******* 2.Clean/contaminated ******* 3.Contaminated 4.Dirty/Infected Note: Chronic inflammation would keep it at a 2 and not bump it to a 3

16. What is the wound class? Patient underwent a breast biopsy. The operative report noted multiple areas of fatty necrosis on the large mass. There was also necrotic tissue around the mass. 1.Clean 2.Clean/contaminated 3.Contaminated * 4.Dirty/Infected

17. What is the wound class? Patient underwent a breast biopsy. The operative report noted multiple areas of fatty necrosis on the large mass. There was also necrotic tissue around the mass. 1.Clean 2.Clean/contaminated ******* 3.Contaminated ******* * 4.Dirty/Infected Note: Necrotic, ischemic dead tissue, without infection is a 3

18. What is the wound class? Patient underwent laparoscopic appendectomy. The pre op CT scan reported the appendix contained a fecalith. There was no mention of infection, rupture or inflammation on the operative report. 1.Clean 2.Clean/contaminated * 3.Contaminated 4.Dirty/Infected

19. What is the wound class? Patient underwent laparoscopic appendectomy. The preop CT scan reported the appendix contained a fecalith. There was no mention of infection, rupture or inflammation on the operative report. 1.Clean ******* 2.Clean/contaminated ******* * 3.Contaminated 4.Dirty/Infected Note: Fecalith contained within GI tract w/o infection or inflammation is a 2

20. What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “inflamed appendix without perforation”. * 1.Clean 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

21. What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “inflamed appendix without perforation”. * 1.Clean 2.Clean/contaminated ******* 3.Contaminated ******** 4.Dirty/Infected Note: Acute inflammation is a 3

22. What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “inflamed appendix without perforation with exudates”. 1.Clean 2.Clean/contaminated 3.Contaminated * 4.Dirty/Infected

23. What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “injected appendix without perforation with exudates”. 1.Clean 2.Clean/contaminated ******* 3.Contaminated ******* * 4.Dirty/Infected Note: Exudates outside of non-perforated injected appendix is a 3

24. What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “acute appendix with perforation”. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

25. What is the wound class? Patient underwent a laparoscopic appendectomy. The operative report states “acute appendix with perforation”. 1.Clean * 2.Clean/contaminated 3.Contaminated ******* 4.Dirty/Infected ******* Note: Perforated appendix assumes infected contents have spilled into abdominal cavity

26. What is the wound class? Patient underwent an exploratory laparoscopic for possible small bowel obstruction. The procedure performed was terminal ileum resection. The operative report states “necrotic cecum and appendix”. 1.Clean 2.Clean/contaminated 3.Contaminated * 4.Dirty/Infected

27. What is the wound class? Patient underwent an exploratory laparoscopic for possible small bowel obstruction. The procedure performed was a terminal ileum resection. The operative report states surgeon found a “necrotic cecum and appendix”. 1.Clean 2.Clean/contaminated ******* 3.Contaminated ******* * 4.Dirty/Infected Note: Necrosis, ischemic dead tissue, is generally not infected

28. What is the wound class? With a patient in significant abdominal pain, a preop CT scan indicated patient had SBO (small bowl obstruction). An ex-lap was performed and adhesion lysis freed up a SBO. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

29. What is the wound class? With a patient in significant abdominal pain, a preop CT scan indicated patient had SBO (small bowl obstruction). An ex-lap was performed and adhesion lysis freed up a SBO. ******* 1.Clean ******* * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected Note: Bowel was never incised, therefore surgery is on par with hernia repair

30. What is the wound class? Patient underwent a rectopexy procedure (rectal prolapse) where a portion of the rectum was resected. The anastamosis was checked for patency/leaks by rigid sigimoidoscopy. 1.Clean 2.Clean/contaminated 3.Contaminated * 4.Dirty/Infected

31. What is the wound class? Patient underwent a rectopexy procedure (rectal prolapse) where a portion of the rectum was resected. The anastamosis was checked for patency/leaks by rigid sigimoidoscopy. 1.Clean ******* 2.Clean/contaminated ******* 3.Contaminated * 4.Dirty/Infected Note: Anal & rectum procedures are 2, unless infection present, e.g. abscess/fistula

32. Vascular Surgery

33. What is the wound class? Patient had necrotic foot d/t complications from peripheral ischemia r/t 150 pack years of smoking. Surgeon performed below knee amputation where the incision was clean without infection. 1.Clean 2.Clean/contaminated 3.Contaminated * 4.Dirty/Infected

34. What is the wound class? Patient had necrotic foot d/t complications from peripheral ischemia r/t 150 pack years of smoking. Surgeon performed below knee amputation where the incision was clean without infection. ******* 1.Clean ******** 2.Clean/contaminated 3.Contaminated * 4.Dirty/Infected Note: Incision was in a clean area, therefore on par with ortho baseline surgery

35. What is the wound class? Long term diabetic patient had infected gangrenous below-the-knee-amputation stump after vascular grafts failed to improve leg perfusion. Surgeon performed above the knee amputation AKA where the initial incision expressed lymphatic pus.AKA surgery successful. 1.Clean 2.Clean/contaminated * 3.Contaminated 4.Dirty/Infected

36. What is the wound class? Long term diabetic patient had infected gangrenous below-the-knee-amputation stump after vascular grafts failed to improve leg perfusion. Surgeon performed above the knee amputation (AKA) where the initial incision expressed lymphatic pus.AKA surgery successful. 1.Clean 2.Clean/contaminated * 3.Contaminated ******* 4.Dirty/Infected ******* Note: Incision cut into infected material

37. Orthopedics

38. What is the wound class? THA for osteoarthritis of left hip. Bone was very good with advanced wear of both surfaces. No evidence of any other disease process. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

39. What is the wound class? THA for osteoarthritis of left hip. Bone was very good with advanced wear of both surfaces. No evidence of any other disease process. ******* 1.Clean ******** * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected Note: Ortho cases are a baseline 1 wound class

40. What is the wound class? Left knee several years status post total knee arthroplasty with rotating platform, status post arthroscopy with aspirate confirming coagulase negative staphylococcal infection. 1.Clean 2.Clean/contaminated 3.Contaminated * 4.Dirty/Infected

41. What is the wound class? Left knee several years status post total knee arthroplasty with rotating platform, status post arthroscopy with aspirate confirming coagulase negative staphylococcal infection. 1.Clean 2.Clean/contaminated 3.Contaminated ******* 4.Dirty/Infected ******* Note: Presence of infection = 4

42. What is the wound class? Open left tib/fib fracture with intramedullary rod fixation, locked proximally and distally. Irrigation/debridement of devitalized tissue d/t compound fracture. 1.Clean 2.Clean/contaminated * 3.Contaminated 4.Dirty/Infected

43. What is the wound class? Open left tib/fib fracture with intramedullary rod fixation, locked proximally and distally. Irrigation/debridement of devitalized tissue d/t compound fracture. 1.Clean 2.Clean/contaminated ******* 3.Contaminated ******* 4.Dirty/Infected Note: Presence of devitalized (necrotic) tissue = 3

44. What is the wound class? Diagnostic arthroscopy, extensive washout, debridement of lateral portal. Extensive grade 3-4 arthritis in all three compartments. No evidence of intra-articular pus. The lateral portal had some soft tissue necrosis which was debrided. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

45. What is the wound class? Diagnostic arthroscopy, extensive washout, debridement of lateral portal. Extensive grade 3-4 arthritis in all three compartments. No evidence of intra-articular pus. The lateral portal had some soft tissue necrosis which was debrided. 1.Clean * 2.Clean/contaminated ******* 3.Contaminated ******* 4.Dirty/Infected Note: Presence of devitalized (necrotic) tissue = 3

46. What is the wound class? Incision and drainage of bilateral lower extremity amputation stumps with gas gangrene bilateral, but no significant collection of any pus seen on the dressings. Wound was very large and necrotic tissue was sharply debrided. 1.Clean * 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

47. What is the wound class? Incision and drainage of bilateral lower extremity amputation stumps with gas gangrene bilateral, but no significant collection of any pus seen. Wound was very large and necrotic tissue was sharply debrided. 1.Clean * 2.Clean/contaminated ******* 3.Contaminated ******* or ******* 4.Dirty/Infected ******* Note: Depends of type of necrosis and if gas gangrene was emanating from debrided tissue.

48. OB/GYN

49. What is the wound class? Laparoscopic total abdominal hysterectomy. * 1.Clean 2.Clean/contaminated 3.Contaminated 4.Dirty/Infected

50. What is the wound class? Laparoscopic total abdominal hysterectomy. * 1.Clean ******* 2.Clean/contaminated ******* 3.Contaminated 4.Dirty/Infected Note: Hysterectomies are a baseline GYN procedure = 2