Cholecystectomy Surgical Wound Classification

Surgical Wound Classification:
Impact on Post-Surgical Outcomes

and Risk Stratification in
Cholecystectomies
Kulvinder Bajwa, MD.,

Surgeon Champion
Michelle Wells, LVN.,

Surgical Clinical Reviewer
July 28, 2014

Disclosure Statement
The following presenters for this

presentation have no relevant financial
relationships with commercial interests to
disclose:
Kulvinder Bajwa, MD
Michelle Wells
This document is privileged and confidential Quality Committee or Peer Review work product under Hospital Committee Privilege contained in the Texas Health and Safety Code 161.031
& 161.032, or Medical Peer Review under the Medical Practice Act, Texas Occupations Code, 151.001 et. seq & 160.007.; and the Medical Peer Review immunity provided by federal
law, the Health Care Quality Improvement Act, 42. U.S.C. 11101, et. seq.
Problem Statement
Problem: Impact on Outcome Reporting:
Identifying and capturing

At Memorial Hermann surgical wound classification
Hospital Sugar Land, in cholecystectomies directly
medical record reviews impacts reporting of post-
surgical outcomes and post-
reflected an accuracy rate
surgical risk stratification.
as low as 37% in
classification and Wound class documentation
documentation of surgical is submitted to National
wound sites by physicians Health and Safety Network
and nursing. (NHSN) and NSQIP for risk
stratification of SSI rates.
Wound Classification
Intent of Variable: To capture an important determinant

of the risk of postoperative infection.
Definition: Wound classification determines the level of

contamination of the surgical wound by estimating the
bacterial load at the surgical site at the time of the
principal operative procedure.
Criteria: Indicate how the wound is classified by the

surgical team
Predicted SSI rates by
Wound Classification*
Clean Wounds less than 2%
Clean/Contaminated range from 4%-10%
Contaminated Wounds can exceed 20%
Dirty Wounds can exceed 40%
*Pear, S. (2007). Patient risk factors and best practices. MANAGING INFECTION CONTROL, March(2007), 56-64.
Retrieved from http://www.kchealthcare.com/media/13929494/patient_risk_factors_best_practices_ssi.pdf
A Few ExamplesB
CLEAN CLEAN CONTAMINATED

Hernia Repair Symptomatic
Mastectomy cholelithiasis
Removal orthopedic Colectomy
hardware (non-infected) TURP
CONTAMINATED DIRTY INFECTED

Acute cholecystitis Abscess drainage
Inflamed appendix Perforated bowel
Gangrenous gallbladder
Dry gangrene Suppurative appendix
Surgical Wound Classifications
To be assigned at the end of the procedure
Robust Process Improvement
The following RPI tools were used to address

correction of process failures and knowledge deficits:
Define: Project Team Charter, Voice of the Customer, and Process
Mapping.
Measure: Data Collection via interviews, observation (surgeries in
progress) and retrospective EHR reviews for surgical wound class
documentation (Perioperative Nursing and Physician Procedure
Notes).
Analyze: Identification of primary contributing factors for
discrepancies.
Improve: Collaborative Team re-evaluation of policies/procedures
and operational definitions with pertinent staff education.
Control: Audit tool for process monitoring and sustainment.
Key Project Actions
Collaborative Re-Evaluation of policies and

procedures: Perioperative team, Surgeons, Quality
Team (Performance Improvement and Infection Control
Practitioners).
Review: Importance of end of case communication (OR
Staff, Surgeons).
Education: OR Staff, Surgeons ( Annual requirement,
New Employee Orientation, Ongoing, as needed).
Implement: Routine compliance monitoring with
leadership follow-up.
Results
Baseline data over 6

months indicated an
accuracy rate as low as
37% in wound
classification.
Post-initiative
outcomes over a 6
month period revealed
79% accuracy (32%
increase).
Results
Accurate identification, reporting and risk

stratification of cholecystectomy post-surgical
outcomes is dependent upon accuracy of
surgical wound class identification.
It is not always necessary to re-invent the

wheel. Evaluation of current policy/processes
along with re-education/re-implementation and
tools for monitoring the process may be all that
is necessary for achieving the project goals.
References
American College of Surgeons National Surgical Quality Improvement

program (2014). NSQIP Training: Chapter 4, Variables and Definitions.
Pear, S. (2007). Patient risk factors and best practices. MANAGING

INFECTION CONTROL, March(2007), 56-64. Retrieved from
http://www.kchealthcare.com/media/13929494/patient_risk_factors_best_pr
actices_ssi.pdf

Cholecystectomy Surgical Wound Classification

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Surgical Wound Classification:

Impact on Post-Surgical Outcomes

Kulvinder Bajwa, MD.,

Michelle Wells, LVN.,

July 28, 2014

The following presenters for this

Problem: Impact on Outcome Reporting:

Identifying and capturing

Intent of Variable: To capture an important determinant

Definition: Wound classification determines the level of

Criteria: Indicate how the wound is classified by the

Clean/Contaminated range from 4%-10%

Contaminated Wounds can exceed 20%

Dirty Wounds can exceed 40%

CLEAN CLEAN CONTAMINATED

CONTAMINATED DIRTY INFECTED

The following RPI tools were used to address

Collaborative Re-Evaluation of policies and

Baseline data over 6

Accurate identification, reporting and risk

It is not always necessary to re-invent the

American College of Surgeons National Surgical Quality Improvement

Pear, S. (2007). Patient risk factors and best practices. MANAGING

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