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JULY 2008, VOL 88, NO 1 Clinical Issues

REFERENCES
1. Houser J. Nursing Research: Reading, Using, and
Creating Evidence. Boston, MA: Jones and Bartlett
Publishers; 2008.
2. Nollan R, Fineout-Overholt E, Stephenson P.
Asking compelling clinical questions. In: Melnyk BM,
Fineout-Overholt E, eds. Evidence-Based Practice in
Nursing and Healthcare: A Guide to Best Practice.
Philadelphia, PA: Lippincott Williams & Wilkins;
2004:25-37.
3. Recommended practices for maintaining a sterile
field. In: Perioperative Standards and Recommended
Practices. Denver, CO: AORN, Inc; 2008:565-573.
4. Recommended practices for preoperative patient
skin 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%20
Conditions.asp. Accessed April 24, 2008.
ROBIN CHARD
RN, PHD, CNOR
PERIOPERATIVE NURSING SPECIALIST
AORN CENTER FOR NURSING PRACTICE
108 AORN JOURNAL
Wound classifications
QUESTION: At my facility, surgical team members
continue to have questions concerning wound
classifications. The Centers for Disease Control
and Prevention (CDC) Guidelines for prevention
of surgical site infection identifies four surgical
wound 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 is
a formula that the surgical team uses for post-
operatively grading the extent of microbial
contamination, indicating the chance that a pa-
tient will develop an infection at the surgical
site.
1
In addition, it assists the surgeon in de-
termining whether or not to use preoperative
antimicrobial prophylaxis. The CDC uses an
adaptation of the American College of Sur-
geons wound classification schema, which di-
vides surgical wounds into four classes.
2

CLASS I/CLEAN WOUNDSan uninfected surgical


wound in which no inflammation is en-
countered and the respiratory, alimentary,
genital, or uninfected urinary tracts are not
entered. In addition, clean wounds are pri-
marily closed and, if necessary, drained
with closed drainage. Surgical wound inci-
sions that are made after nonpenetrating (ie,
blunt) trauma should be included in this
category if they meet the criteria.

CLASS II/CLEAN-CONTAMINATED WOUNDSa surgical


wound in which the respiratory, alimentary,
genital, or urinary tracts are entered under
controlled conditions and without unusual
contamination. Specifically, surgical proce-
dures involving the biliary tract, appendix,
vagina, and oropharynx are included in this
category, provided no evidence of infection
is 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 sterile
technique occurs (eg, open cardiac massage)
or there is gross spillage from the gastroin-
testinal tract and incisions in which acute,
nonpurulent inflammation is encountered
are included in this category.

CLASS IV/DIRTY OR INFECTED WOUNDSold traumat-


ic wounds with retained or devitalized tis-
sue and those that involve existing clinical
infection or perforated viscera. This defini-
tion suggests that the organisms causing
postoperative infection were present in the
wound before the surgical procedure.
The schema is considered the gold standard
by which wounds are classified. Areas not
specifically addressed in the CDC document
include wounds in pediatric patients;
3
proce-
dures performed outside of the OR such as
from endoscopic procedures, cardiac catheteri-
zations, and interventional radiology; and sur-
gical wounds unique to minimally invasive
procedures.
Exclusion of the above situations requires clin-
ical judgment when ambiguity exists in deter-
mining how to classify a wound. Consultation
with an infection control practitioner may be
needed but the ultimate decision should be made
by the surgeon. The following is a sampling of
Clinical Issues JULY 2008, VOL 88, NO 1
procedures for which perioperative nurses have
questioned what classification to apply:

Wounds with an open drain (ie, Penrose


drain)class II

Rationale: open drains increase the risk of


surgical site infection.
1

Laparoscopic removal of an ectopic preg-


nancyclass I

Rationale: no inflammation or rupture is


present.

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 uterine


manipulator is usedclass II

Rationale: the vagina, an area of higher


contamination, is entered; therefore, the
wound classification defaults to the next
higher level.

Amputation for dry gangrene (ie, tissue death


without presence of infection)class III

Rationale: nonpurulent inflammation is


present.

Amputation for wet gangrene (ie, infected


by saprogenic microorganisms)class IV

Rationale: devitalized tissue is present


and the microbial load is greater.
The term major break is used throughout the
wound classification schema although it is not
clearly defined in regard to aseptic technique;
therefore, clinical judgment again becomes in-
strumental. Major breaks in aseptic technique
may include those that come in direct contact
with a patient (ie, skin-to-skin) or those that
are 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 in
preventing surgical site infections.
REFERENCES
1. Mangram AJ, Horan TC, Pearson ML, Silver LC,
Jarvis WR; the Hospital Infection Control Practices
Advisory Committee. Guideline for prevention of
surgical 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 the
operating room and of various other factors. Ann
Surg. 1964;160(Suppl 2):1-192.
3. Horwitz JR, Chwals WJ, Doski JJ, Suescun EA,
Cheu HW, Lally KP. Pediatric wound infections: a
prospective multicenter study. Ann Surg. 1998:227
(4):553-558.
ROBIN CHARD
RN, PHD, CNOR
PERIOPERATIVE NURSING SPECIALIST
AORN CENTER FOR NURSING PRACTICE
AORN JOURNAL 109
Editors note: At various times throughout the year, the Recom mended Practices Committee seeks
review and comment on proposed recommended practices from members and other interested indi-
viduals. When available, these proposed recommended practices appear on AORN Online at
http:// www .aorn.org. Proposed recommended practice documents are available for review and
comment for a 30-day period after they are posted. Interested individuals who do not have access to
the Internet may obtain copies of the proposed documents by calling the Center for Nursing Practice
at (800) 755-2676 x 334. A deadline for comments is indicated with each document. Please check
these sources frequently to locate proposed recommended practices. All comments received are con-
sidered as the document is finalized. Thank you for your participation.

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