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Surgical Wound Classification: Communication Is Needed for Accuracy

Article  in  AORN journal · February 2012

DOI: 10.1016/j.aorn.2011.10.013 · Source: PubMed

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PATIENT SAFETY FIRST
Surgical Wound
Classification:
Communication Is
Needed for Accuracy
JENNIFER L. ZINN, MSN, RN, CNS-BC, CNOR
S
urgical wound classification is informa-
tion that most circulating nurses docu-
ment on a patient’s record at the end of
a surgical procedure. Nurses must understand
the different classifications and the process of
assigning categories to ensure that wound clas-
sification is accurate.
In 1964, the National Academy of Sciences
National Research Council1 published its land-
mark study on the use of ultraviolent lights in the
OR, and the era of classifying wounds by the
contamination present (or the potential for con-
tamination) began.2-4 Classifying wounds be-
came one method of predicting a surgical pa-
tient’s risk of an infection3,4 based on an
assessment of the degree of bacterial load (ie,
contamination of a surgical wound) observed at
the time of surgery.2,3,5,6 The American College
of Surgeons7 defined the initial wound classifi-
cation categories, and the Centers for Disease
Control and Prevention adapted these categories
into the current guidelines that were issued in
1985.8,9 Using this traditional system to define
wound classification, surgical procedures are
placed into one of four categories:
The AORN Journal is seeking contributors for the Patient Safety First column. Interested authors can contact
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274 AORN Journal ● February 2012 Vol 95 No 2
 clean (class I),
 clean/contaminated (class II),
 contaminated (class III), and
2,3,5
 dirty/infected (class IV).
Several factors affect the potential for surgical
site infection development and contribute to the
assignment of wound classification.9 These factors
include, but are not limited to,
 the location of the surgery,
 the presence of acute inflammation,
 a major break in sterile technique, and
 the presence of existing infection at the
surgical site.6,9
In many outcome studies, wound classification is
an important data point collected as a predictor of
postoperative infection and its associated risks.2,6
Wound classification plays an important role in
identifying risk-adjusted outcomes that drive qual-
ity improvement initiatives.2 In addition, wound
classification and risk-adjusted outcomes are in-
creasingly used for reporting and analyzing clini-
cal care.2 Risk-adjustment analysis allows for
more consistent evaluation of the outcomes deliv-
ered by health care providers, and documentation
doi: 10.1016/j.aorn.2011.10.013
© AORN, Inc, 2012
PATIENT SAFETY FIRST www.aornjournal.org

must be accurate for the analyses to be effective.2
Incorrect capturing of the data point for wound
classification can skew results and potentially re-
flect invalid outcomes.6
WOUND CLASSIFICATION
Wound classification should be determined and
documented at the end of the surgical procedure
to accurately reflect and capture any events that
may have occurred during the procedure that
would affect wound classification.6,9 Examples of
this include the following:
 A surgeon is about to close the fascia during
an exploratory laparotomy when a surgical
team member notices a tear in the back table
drape. In this instance, a major break in sterile
technique has occurred and the circulating
nurse would need to change the initial wound
classification of clean/class I to contaminated/
class III.
 A surgeon is about to remove the patient’s
gallbladder during an uneventful laparoscopic
cholecystectomy when the gallbladder tears
and bile stones spill into the abdomen. In this
example, the circulating nurse would change
the initial wound classification of clean/
contaminated/class II to contaminated/class III
because of the gross bile spillage.
An understanding of what constitutes a wound
class is important for the perioperative nurse to
accurately assess and document wound classifica-
tion. Decision algorithms
can help in making these
determinations (Figure 1). AORN Resources
Clean/Class I Wounds  Periop Modules: Patient Care Modules. Wound Closure and
A clean or class I surgical Healing. http://www.aorn.org/Education/ContinuingEducation/
wound is one that does not PeriopModules/. Accessed October 11, 2011.
enter the respiratory, gastro-  Recommended practices for prevention of transmissible infec-
wounds are closed primarily (ie, sutured or ap-
proximated in some other way), and if a drain is
present, it drains into a closed system. The risk of
developing an infection from a clean wound is
approximately 2%.4 Infections that do occur in
clean wounds are largely a result of gram-positive
organisms such as Staphylococcus aureus. Exam-
ples of a clean wound include incisions made for
hernia repair, exploratory laparotomy, mastec-
tomy, or vascular bypass graft harvest.2,4,6,9
Clean/Contaminated/Class II Wounds
A clean/contaminated or class II surgical wound
is one that enters the respiratory, GI, genital, or
urinary tract in a controlled manner (ie, intention-
ally). These wounds are uninfected, and no acute
inflammation is present. The risk of developing
an infection from a clean/contaminated wound is
approximately 5% to 15% and is largely a result
of endogenous flora and bacteria from within the
patient.4 Examples of procedures classified as
clean/contaminated include hysterectomy, colec-
tomy, lung lobectomy, or cholecystectomy for
stones or chronic inflammation.2,4,6,9
Contaminated/Class III Wounds
An open, fresh (ie, less than four hours old), acci-
dental wound is classified as contaminated. Surgi-
cal procedures that result in contaminated wounds
include those with acute, nonpurulent inflamma-
tion; a major break in sterile technique; or gross
spillage from the GI tract. An active infection is
not present in a contaminated wound. The risk of

intestinal (GI), genital, or tions in the perioperative practice setting. In: Perioperative
urinary tract. These wounds Standards and Recommended Practices. Denver, CO: AORN,
are uninfected, and no in- Inc; 2012:341-352.
flammation is present. Clean

AORN Journal 275

February 2012 Vol 95 No 2
Figure 1. Wound class algorithm. Reprinted with permission from Cone Health, Greensboro, NC.
developing an infection from a contaminated
wound, however, is greater than 15%, largely be-
cause of endogenous leakage or delayed exoge-
nous contamination introduced into the surgical
wound during the procedure.4 Examples of proce-
dures that result in a contaminated wound include
appendectomy for acute appendicitis, open cardiac
massage, or cholecystectomy with acute inflam-
mation and bile spillage.2,4,6,9
276 AORN Journal
PATIENT SAFETY FIRST
Dirty/Infected/Class IV Wounds
An old (ie, more than four hours old), traumatic
wound containing retained devitalized tissue is
considered dirty or infected. This classification
includes wounds that involve an area with an ex-
isting clinical infection or perforated viscera and
suggest the infection was present in the surgical
field before the incision was made. The risk of
developing an infection from a contaminated
PATIENT SAFETY FIRST
wound is greater than 30% and is largely the re-
sult of existing infection from unusual or patho-
genic organisms.4 Examples of procedures in
which the wound is contaminated include appen-
dectomy for a ruptured appendix, appendectomy
with the presence of pus, surgical treatment of an
abscess, the irrigation and debridement of a peri-
rectal abscess, or the repair of a perforated bowel
or perforated gastric ulcer.2,4,6,9 An infectious
process that is present but not near the surgical
site does not affect wound classification.9
THE ROLE OF THE PERIOPERATIVE
NURSE
Perioperative nurses play a pivotal role in actively
communicating and collaborating with health care
team members to ensure the accuracy of the clini-
cal data they are documenting.2 In fact, communi-
cation is a key component for patient safety in
any arena in the continuum of patient care.10
Lack of communication between team members is
commonly cited as the cause of adverse patient
events, and many patient safety and quality im-
provement initiatives focus on improving team
communication methods.10 Building a culture
of communication is rooted in and results in
good teamwork.11 Good teamwork behaviors
lead to positive patient outcomes when all staff
members are encouraged to speak up about any
patient safety concern.11 Tools are available to
help guide surgical team members’ patient
safety conversations.10,11 Some of these tools
include checklists or briefing and debriefing
tools. These tools empower surgical team mem-
bers to identify and resolve patient safety issues
that may cause harm if not addressed.10,11 Us-
ing these tools provides a framework to culti-
vate teamwork and communication with the
ultimate goal of improving performance and
safety for the patient.11
Adding wound classification to an existing
checklist or debriefing tool is an effective way to
enhance the communication of the entire surgical
team regarding the assignment of wound classifi-
www.aornjournal.org
cation and assessment of the surgical field.
Wound classification requires an active conversa-
tion between the surgeon, the perioperative nurse,
and the other team members and should not be
made by independent nursing assignment of class-
fication.6 Without this communication, the circu-
lating nurse may be unaware of changes in the
procedure that would alter the classification and
could affect the patient’s outcome. Other inter-
ventions that can immediately be practiced to pos-
itively affect wound classification include
 using a standardized system for wound
classification,2,6
 maintaining sterile technique and identifying
when a break occurs, and
 accurately documenting all elements in the
surgical record.
CONCLUSION
Wound classification is an important clinical activity
that nurses must routinely document in the patient’s
surgical record. Accurate documentation of wound
classification is essential for preventing and tracking
surgical infections and ensuring positive surgical
outcomes for patients. Perioperative nurses play a
key role in documenting this important data point,
and it is imperative that they understand the defini-
tion and significance of wound classification assign-
ment. For the patient’s sake, nurses also must con-
tinue to actively communicate with the entire
surgical team to ensure that wound classifications
are accurate.
References
1. Berard F, Gandon J. Postoperative wound infection: the
influence of ultraviolet radiation of the operating room and
various other factors. Ann Surg. 1964;160(Suppl 2):1-192.
2. Devaney L, Rowell K. Improving surgical wound
classification—why it matters. AORN J. 2004;80(2):
208-223.
3. Cardo DM, Falk PS, Mayhall CG. Validation of surgi-
cal wound classification in the operating room. Infect
Control Hosp Epidemiol. 1993;14(5):225-259.
4. Nichols R. Classification of the surgical wound: a time
for reassessment and simplification. Infect Control Hosp
Epidemiol. 1993;14(5):253-254.
5. Paige J. Tissue handling. In: Rothrock J, Seifert P, eds.
Assisting in Surgery: Patient-Centered Care. Denver,
AORN Journal 277
 February 2012 Vol 95 No 2 PATIENT SAFETY FIRST

CO: Competency & Credentialing Institute; 2009;
74-106.
6. Zinn J, Swofford V. What is wound classification?
Speech presented at: The 58th Annual AORN Con-
gress; March 18, 2010; Denver, CO.
7. Committee on Control of Surgical Infections of the
Committee on Pre and Postoperative Care, American
College of Surgeons. Manual on Control of Infection in
Surgical Patients. Philadelphia, PA: JB Lippincott
Company; 1984.
8. Garner JS. CDC guideline for prevention of surgical
wound infections, 1985. Supersedes guideline for the
prevention of surgical wound infections published in
1982. (Originally published in 1985). Revised. Infect
Control. 1986;7(3):193-200. http://wonder.cdc.gov/
wonder/prevguid/p0000420/p0000420.asp. Accessed
September 1, 2011.
9. Burlingame B. OR fire extinguishers; classifying
wounds and minor procedure; antibiotic infusion time;
mopping after minor procedures [Clinical Issues].
AORN J. 2006;83(6):1384-1393.
10. Lingard L, Regehr G, Orser B, et al. Evaluation of a
preoperative checklist and team briefing among sur-
geons, nurses, and anesthesiologists to reduce failures
in communication. Arch Surg. 2008;143(1):12-17.
11. Makary MA, Sexton JB, Freischlag JA, et al. Operating
room teamwork among physicians and nurses: team-
work is in the eye of the beholder. J Am Coll Surg.
2006;202(5):746-752.
Jennifer L. Zinn, MSN, RN, CNS-BC,
CNOR, is a clinical nurse specialist in Opera-
tive Services at Cone Health, Greensboro, NC.
Ms Zinn has no declared affiliation that could
be perceived as posing a potential conflict of
interest in the publication of this article.

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