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JULY 2008, VOL 88, NO 1 Clinical Issues

REFERENCES1. Houser J. Nursing Research: Reading, Using, andCreating Evidence. Boston, MA: Jones and BartlettPublishers; 2008.

2. Nollan R, Fineout-Overholt E, Stephenson P.Asking compelling clinical questions. In: Melnyk BM,Fineout-Overholt E, eds. Evidence-Based Practice inNursing and Healthcare: A Guide to Best Practice.Philadelphia, PA: Lippincott Williams & Wilkins;2004:25-37.3. Recommended practices for maintaining a sterilefield. In: Perioperative Standards and RecommendedPractices. Denver, CO: AORN, Inc; 2008:565-573.

4. Recommended practices for preoperative patientskin antisepsis. In: Perioperative Standards and Recom-mended Practices. Denver, CO: AORN, Inc; 2008:653-656.5. Centers for Medicare and Medicaid Services.

Hospital-acquired conditions. http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired%20Conditions.asp. Accessed April 24, 2008.

ROBIN CHARDRN, PHD, CNOR

PERIOPERATIVE NURSING SPECIALIST

AORN CENTER FOR NURSING PRACTICE

108 AORN JOURNAL

Wound classifications

QUESTION: At my facility, surgical team memberscontinue to have questions concerning woundclassifications. The Centers for Disease Controland Prevention (CDC) Guidelines for preventionof surgical site infection identifies four surgicalwound classifications.1 Can AORN provide exam-ples of wound classifications for surgical proce-dures that are not mentioned by the CDC?

ANSWER: The wound classification system isa formula that the surgical team uses for post-operatively grading the extent of microbialcontamination, indicating the chance that a pa-tient will develop an infection at the surgicalsite.1 In addition, it assists the surgeon in de-termining whether or not to use preoperativeantimicrobial prophylaxis. The CDC uses anadaptation of the American College of Sur-geons wound classification schema, which di-vides surgical wounds into four classes.2

CLASS I/CLEAN WOUNDSan uninfected surgicalwound in which no inflammation is en-countered and the respiratory, alimentary,genital, or uninfected urinary tracts are notentered. In addition, clean wounds are pri-marily closed and, if necessary, drainedwith closed drainage. Surgical wound inci-sions that are made after nonpenetrating (ie,

blunt) trauma should be included in thiscategory if they meet the criteria.

CLASS II/CLEAN-CONTAMINATED WOUNDSa surgicalwound in which the respiratory, alimentary,genital, or urinary tracts are entered undercontrolled conditions and without unusualcontamination. Specifically, surgical proce-

dures involving the biliary tract, appendix,vagina, and oropharynx are included in thiscategory, provided no evidence of infectionis encountered and no major break in tech-nique occurs.

CLASS III/CONTAMINATED WOUNDSopen, fresh, ac-cidental wounds. In addition, surgical pro-cedures in which a major break in steriletechnique occurs (eg, open cardiac massage)

or there is gross spillage from the gastroin-testinal tract and incisions in which acute,nonpurulent inflammation is encounteredare included in this category.

CLASS IV/DIRTY OR INFECTED WOUNDSold traumat-ic wounds with retained or devitalized tis-sue and those that involve existing clinicalinfection or perforated viscera. This defini-tion suggests that the organisms causingpostoperative infection were present in thewound before the surgical procedure.The schema is considered the gold standard

by which wounds are classified. Areas notspecifically addressed in the CDC documentinclude wounds in pediatric patients;3 proce-dures performed outside of the OR such asfrom endoscopic procedures, cardiac catheteri-zations, and interventional radiology; and sur-gical wounds unique to minimally invasiveprocedures.

Exclusion of the above situations requires clin-

icaljudgment when ambiguity exists in deter-mining how to classify a wound. Consultationwith an infection control practitioner may beneeded but the ultimate decision should be madeby the surgeon. The following is a sampling of

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procedures for which perioperative nurses havequestioned what classification to apply:

Wounds with an open drain (ie, Penrosedrain)class II

Rationale: open drains increase the risk ofsurgical site infection.1

Laparoscopic removal of an ectopic preg-nancyclass I

Rationale: no inflammation or rupture ispresent.

Laparoscopic cholecystectomyclass II Rationale: the gallbladder, which is part of

the biliary tract, is entered under a con-trolled environment.

Cystoscopyclass II Rationale: the urinary tract is entered

under a controlled environment.

Laparoscopic procedure in which a uterinemanipulator is usedclass II

Rationale: the vagina, an area of highercontamination, is entered; therefore, thewound classification defaults to the nexthigher level.

Amputation for dry gangrene (ie, tissue death

without presence of infection)class III Rationale: nonpurulent inflammation is

present.

Amputation for wet gangrene (ie, infectedby saprogenic microorganisms)class IV

Rationale: devitalized tissue is presentand the microbial load is greater.

The term major breakis used throughout the

wound classification schema although it is notclearly defined in regard to aseptic technique;therefore, clinicaljudgment again becomes in-strumental. Major breaks in aseptic techniquemay include those that come in direct contactwith a patient (ie, skin-to-skin) or those thatare indirect through a malfunction of environ-mental controls.

As of October 1, 2008, The Centers for Medi-care & Medicaid Services no longer will reim-

burse facilities for certain hospital-acquired con-ditions. Correctly classifying a wound, therefore,

becomes an important piece of the puzzle inpreventing surgical site infections.

REFERENCES1. Mangram AJ, Horan TC, Pearson ML, Silver LC,

Jarvis WR; the Hospital Infection Control PracticesAdvisory Committee. Guideline for prevention ofsurgical site infection, 1999. Infect Control Hosp Epi-demiol. 1999;20(4):250-278.2. Berard F, Gandon J. Postoperative wound infec-tions: the influence of ultraviolet irradiation of theoperating room and of various other factors.AnnSurg. 1964;160(Suppl 2):1-192.3. Horwitz JR, Chwals WJ, Doski JJ, Suescun EA,

Cheu HW, Lally KP. Pediatric wound infections: aprospective multicenter study.Ann Surg. 1998:227(4):553-558.

ROBIN CHARDRN, PHD, CNOR

PERIOPERATIVE NURSING SPECIALIST

AORN CENTER FOR NURSING PRACTICE

AORN JOURNAL 109

Editors note:At various times throughout the year, the Recommended Practices Committee seeksreview and comment on proposed recommended practices from members and other interested indi-viduals. When available, these proposed recommended practices appear on AORN Online athttp://www.aorn.org. Proposed recommended practice documents are available for review andcomment for a 30-day period after they are posted. Interested individuals who do not have access tothe Internet may obtain copies of the proposed documents by calling the Center for Nursing Practiceat (800) 755-2676 x 334. A deadline for comments is indicated with each document. Please checkthese sources frequently to locate proposed recommended practices. All comments received are con-sidered as the document is finalized. Thank you for your participation.