All Surgical Specialty Wound Class Review

1
All Surgical Specialty Wound Class Review Quiz

• Bruce Ryon, RN, MS, PhD
• Director, Performance Excellence
• National Surgical Quality Improvement Program
• bruce.r.ryon_at_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 material NOT 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
Baseline Procedures Wound Class

• 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

Bruce Ryon, RN, MS, PhD
9
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 gt27 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
51
What is the wound class?

• 19 Y female patient with undesired pregnancy at
  18w underwent a DE with IUD insertion. No
  unusual findings intraop.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

52
What is the wound class?

• 19 Y female patient with undesired pregnancy at
  18w underwent a DE with IUD insertion. No
  unusual findings intraop.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note DE, DCs IUD insertion w/o inflammation
or infection are baseline 2
53
What is the wound class?

• Patient underwent lap ovarian cystectomy with
  lysis of adhesions (LOA) to gain clear access to
  ovaries. A small hemorrhagic cyst on the left
  ovary was evacuated. Obliteration of cul de sac
  consistent with stage 4 endometriosis.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

54
What is the wound class?

• Patient underwent lap ovarian cystectomy with
  lysis of adhesions (LOA) to gain clear access to
  ovaries. A small hemorrhagic cyst on the left
  ovary which was evacuated. Obliteration of cul de
  sac consistent with stage 4 endometriosis.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note Cystectomy that does not incise ovarian
tract 1, LOA 1 Cystectomy that does incise
ovarian tract 2
55
What is the wound class?

• Patient underwent a Cesarean section with
  prolonged labor (gt 20 hours), ruptured over 18
  hours, thick meconium, no s/sx of infection.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

56
What is the wound class?

• Patient underwent a Cesarean section with
  prolonged labor (gt 20 hours), ruptured over 18
  hours, thick meconium, no s/sx of infection.
• 1.Clean
• 2.Clean/contaminated (baseline c-section)
• 3.Contaminated
• 4.Dirty/Infected

Note Presence of possible non-sterile material
not normally a part of organ flora
57
What is the wound class?

• Patient underwent a Cesarean section d/t PROM and
  maternal temperature over 38C/100.4F, most likely
  due to chorioamnioitis perforation.
• 1.Clean
• 2.Clean/contaminated (baseline c-section)
• 3.Contaminated
• 4.Dirty/Infected

58
What is the wound class?

• Patient underwent a Cesarean section d/t PROM and
  maternal temperature over 38C/100.4F, most likely
  due to chorioamnioitis perforation.
• 1.Clean
• 2.Clean/contaminated (baseline c-section)
• 3.Contaminated
• 4.Dirty/Infected

Note Presence of infected material from
chorioamnioitis perforation
59
What is the wound class?

• Patient underwent a lap fallopian tube ligation
  with Filshie clips placed with good blanching and
  completely encompassing the tubes. There was no
  bleeding on final inspection.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

60
What is the wound class?

• Patient underwent a lap fallopian tube ligation
  with Filshie clips placed with good blanching and
  completely encompassing the tubes. There was no
  bleeding on final inspection.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note the fallopian tubes were not incised or
penetrated 1
61
What is the wound class?

• Patient underwent a fallopian tube ligation at
  the end of a Cesarean section, 3 cm segments of
  tube
• ligated with two free ties of plain gut and
  excised on both fallopian tubes. The lumina were
  visible and hemostasis was noted.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

62
What is the wound class?

• Patient underwent a fallopian tube ligation at
  the end of a Cesarean section, 3 cm segments of
  tube
• ligated with two free ties of plain gut and
  excised on both fallopian tubes.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note the fallopian tubes were incised 2, the
c-section 2
63
What is the wound class?

• Elderly patient underwent a colpocleisis le forte
  type as part of a joint general and gynecology
  surgery for a colovaginal fistula. Pus was found
  along abscess.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

64
What is the wound class?

• Elderly patient underwent a colpocleisis le forte
  type as part of a joint general and gynecology
  surgery for a colovaginal fistula. Pus was found
  along abscess.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note ongoing infection 4
65
Urology
66
What is the wound class?

• The patient had a large exophytic tumor on the
  lower lateral portion of the right kidney. A
  hand port technique was used to excise the tumor
  and do the renorrhaphy.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

67
What is the wound class?

• The patient had a large exophytic tumor on the
  lower lateral portion of the right kidney. A
  hand port technique was used to excise the tumor
  and do the renorrhaphy.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note Incision into renal/urinary tract 2
68
What is the wound class?

• The patient had a very subtle firm nodule in the
  left testicle as well as palpable firm mass in
  his abdomen that could be felt while asleep under
  anesthesia. A left radical orchiectomy was
  performed in standard fashion.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

69
What is the wound class?

• The patient had a very subtle firm nodule in the
  left testicle as well as palpable firm mass in
  his abdomen that could be felt while asleep under
  anesthesia. A left radical orchiectomy was
  performed in standard fashion.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note Incision into reproductory tract 2
70
What is the wound class?

• The patient underwent a repeat transurethral
  resection of the prostate without difficulty.
  There was no evidence of any intravesical
  lesions. There was no evidence of any
  perforation or uncontrolled bleeding at any point.

1.Clean 2.Clean/contaminated 3.Contaminated
4.Dirty/Infected
71
What is the wound class?

• The patient underwent a repeat transurethral
  resection of the prostate without difficulty.
  There was no evidence of any intravesical
  lesions. There was no evidence of any
  perforation or uncontrolled bleeding at any point.

1.Clean 2.Clean/contaminated
3.Contaminated 4.Dirty/Infected
Note Incision into renal/urinary tract 2
72
What is the wound class?

• Patient underwent a vasectomy. The portion of vas
  outside the body was incised. The vas was
  clamped between two Mosquito clamps and the
  portion between the clamp was severed. The vas
  stumps proximal and distal were cauterized.

1.Clean 2.Clean/contaminated 3.Contaminated
4.Dirty/Infected
73
What is the wound class?

• Patient underwent a vasectomy. The portion of vas
  outside the body was incised. The vas was
  clamped between two Mosquito clamps and the
  portion between the clamp was severed. The vas
  stumps proximal and distal were cauterized.

1.Clean 2.Clean/contaminated
3.Contaminated 4.Dirty/Infected
Note Incision into reproductory tract 2
74
What is the wound class?

• The patient underwent a radical spermatic cord
  resection for recurrent phlegmon. The phlegmon
  was carefully delivered from the scrotum into the
  operative field and gently expressed through the
  incision.

1.Clean 2.Clean/contaminated 3.Contaminated
4.Dirty/Infected
75
What is the wound class?

• The patient underwent a radical spermatic cord
  resection for recurrent phlegmon. The phlegmon
  was carefully delivered from the scrotum into the
  operative field and gently expressed through the
  incision.

1.Clean 2.Clean/contaminated
3.Contaminated
4.Dirty/Infected
2 or 3 wound class depends on if phlegmon was
acute or chronic
76
Head and Neck
77
What is the wound class?

• Tympanoplasty with R posterior perforation 30.
  Thick tymapnosclerosis at the anterior border of
  perforation extending within the perforation
  forward.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

78
What is the wound class?

• Tympanoplasty with R posterior perforation 30.
  Thick tymapnosclerosis at the anterior border of
  perforation extending within the perforation
  forward.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note Ear drum not populated by friendly flora
79
What is the wound class?

• Patient underwent myringotomy with insertion of
  tube for media otitis and eustachian tube
  dysfuntion.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

80
What is the wound class?

• Patient underwent myringotomy with insertion of
  tube for media otitis and eustachian tube
  dysfuntion.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note Otitis media is an acute inflammation
process.
81
What is the wound class?

• Patient underwent thyroplasty with medialization
  for vocal cord paralysis.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

82
What is the wound class?

• Patient underwent thyroplasty with medialization
  for vocal cord paralysis.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note Thyroid and surrounding tissue are clean
tissue
83
What is the wound class?

• Patient underwent nasal septoplasty w turbinate
  reduction and nasal closed reduction fracture
  without s/s of inflammation or infection.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

84
What is the wound class?

• Patient underwent nasal septoplasty w turbinate
  reduction and nasal closed reduction fracture
  without s/s of inflammation or infection.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note Baseline nasal surgeries are 2
85
What is the wound class?

• Patient underwent thyroglossal duct cyst
  excision without s/s of inflammation or
  infection.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

86
What is the wound class?

• Patient underwent thyroglossal duct cyst
  excision without s/s of inflammation or
  infection.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note Baseline pharnyx surgeries 2
87
Plastics
88
What is the wound class?

• Patient with excess skin and adiposity of the
  abdomen underwent abdominoplasty with rectus
  plication, in addition to bilateral medial thigh
  lifts. Surgery was uncomplicated.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

89
What is the wound class?

• Patient with excess skin and adiposity of the
  abdomen underwent abdominoplasty with rectus
  plication, in addition to bilateral medial thigh
  lifts. Surgery was uncomplicated.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note Baseline plastics procedures 1
90
What is the wound class?

• Patient underwent nail unit excision, distal
  phalanx shortening, and primary closure d/t
  lesion (nailfold melanocytic proliferation). No
  unusual findings during the case.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

91
What is the wound class?

• Patient underwent nail unit excision, distal
  phalanx shortening, and primary closure d/t
  lesion (nailfold melanocytic proliferation). No
  unusual findings during the case.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note Baseline plastics procedures 1
92
What is the wound class?

• 15 yo patient with underwent a vaginoplasty r/t
  adrenal hyperplasia. Case was completed without
  complication.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

93
What is the wound class?

• 15 yo patient with underwent a vaginoplasty r/t
  adrenal hyperplasia. Case was completed without
  complication.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note Reproductory tract surgeries 2
94
What is the wound class?

• Debridement of surgical wound. Necrotic skin,
  soft tissue as well as muscle of right groin
  incision with lateral pockets composed of dead
  fat and seroma fluid. Cultures sent from the OR
  for aerobic and anaerobic cultures. No drains. No
  complications.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

95
What is the wound class?

• Debridement of surgical wound. Findings necrotic
  skin, soft tissue as well as muscle of right
  groin incision with lateral pockets composed of
  dead fat and seroma fluid. Cultures sent from the
  OR for aerobic and anaerobic cultures. No drains.
  No complications.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated or
• 4.Dirty/Infected

Note Dry necrotic skin 3. PostOp labs indicate
tissue was infected 4
96
What is the wound class?

• Quadriplegic patient underwent debridement and
  flap closure for a chronic left ischial pressure
  sore Stage IV with non-healing of wound Cultures
  of the wound have grown out multiple organisms.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

97
What is the wound class?

• Quadriplegic patient underwent debridement and
  flap closure for a chronic left ischial pressure
  sore Stage IV with non-healing of wound Cultures
  of the wound have grown out multiple organisms.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note Infected wound 4
98
What is the wound class?

• 30-year-old Asian female underwent scar revision
  by initial excision at Stage I with VAC dressing
  delay. She is 18 months status post chemical burn
  to her left upper trunk, neck and face. Previous
  skin grafting is noted to be extremely thick with
  some contracture bands along the neck.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

99
What is the wound class?

• 30-year-old Asian female underwent scar revision
  by initial excision at Stage I with VAC dressing
  delay. She is 18 months status post chemical burn
  to her left upper trunk, neck and face. Previous
  skin grafting is noted to be extremely thick with
  some contracture bands along the neck.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note Class 2 is reserved for baseline tracts
where friendly flora is homeostatic.
100
Ophthalmology
101
What is the wound class?

• 57 year old male patient underwent cataract
  surgery. Case was completed without complication.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

102
What is the wound class?

• 57 year old male patient underwent cataract
  surgery. Case was completed without complication.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note Baseline eye surgeries 1
103
Cardiac Vascular and Thoracic
104
What is the wound class?

• 76 year old male was with extensive CAD was
  brought into the OR for an internal mammary CABG
  procedure. There was dense pericarditis observed
  after the midsternotomy. Revascularization
  included LAD graft to LIMA and PDA was grafted
  with separate segment of RSVG.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

105
What is the wound class?

• 76 year old male was with extensive CAD was
  brought into the OR for an internal mammary CABG
  procedure. There was dense pericarditis observed
  after the midsternotomy. Revascularization
  included LAD graft to LIMA and PDA was grafted
  with separate segment of RSVG.
• 1.Clean if chronic pericarditis
• 2.Clean/contaminated
• 3.Contaminated if acute
  pericarditis
• 4.Dirty/Infected

106
What is the wound class?

• Aortic valve replacement and repair of the
  ascending thoracic aortic aneurysm with a 32 mm
  Terumo tube graft was completed on a 58 year old
  male. The pt was transferred to the CV ICU and a
  transesophageal echocardiography revealed (TEE) a
  well-seated valve without evidence of
  perivalvular leak.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

107
What is the wound class?

• Aortic valve replacement and repair of the
  ascending thoracic aortic aneurysm with a 32 mm
  Terumo tube graft was completed on a 58 year old
  male. The pt was transferred to the CV ICU and a
  transesophageal echocardiography (TEE) revealed a
  well-seated valve without evidence of
  perivalvular leak.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note Baseline heart surgeries 1
108
What is the wound class?

• A wedge resection of the right upper lobe as well
  as mechanical pleurodesis was performed. The apex
  of the right lung was abnormal with multiple
  microscopic blebs, but no gross bullae.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

109
What is the wound class?

• A wedge resection of the right upper lobe as well
  as mechanical pleurodesis was performed. The apex
  of the right lung was abnormal with multiple
  microscopic blebs, but no gross bullae.
• 1.Clean
• 2.Clean/contaminated
• 3.Contaminated
• 4.Dirty/Infected

Note Baseline lung surgeries 2
110
All Surgical Specialty Wound Class Review Quiz

• Bruce Ryon, RN, MS, PhD
• Director, Performance Excellence
• National Surgical Quality Improvement Program
• bruce.r.ryon_at_kp.org