CONTINUING EDUCATION Clinical Issues 1.7 www.aorn.org/CE SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA(E), CPSN-R, PLNC; SCOTT A. BRUBAKER, CTBS Continuing Education Contact Hours Approvals indicates that continuing education (CE) contact hours are This program meets criteria for CNOR and CRNFA recerti- available for this activity. Earn the CE contact hours by fication, as well as other CE requirements. reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http:// AORN is provider-approved by the California Board of www.aorn.org/CE. Each applicant who successfully completes Registered Nursing, Provider Number CEP 13019. Check this program can immediately print a certificate of completion. with your state board of nursing for acceptance of this activity for relicensure. Event: #15532 Session: #0001 Fee: Members $13.60, Nonmembers $27.20 Conflict-of-Interest Disclosures The contact hours for this article expire September 30, 2018. Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA(E), Pricing is subject to change. CPSN-R, PLNC, and Scott A. Brubaker, CTBS, have no declared affiliations that could be perceived as posing a po- fl Purpose/Goal tential con ict of interest in the publication of this article. To provide the learner with knowledge of AORN’s guidelines The behavioral objectives for this program were created by related to surgical wound classification; storing and using Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, small, prefilled containers of formalin in the OR; latex-free with consultation from Susan Bakewell, MS, RN-BC, direc- environments for tissue recovery and organ procurement tor, Perioperative Education. Ms Starbuck Pashley and Ms procedures; covering facial hair in semirestricted and restricted Bakewell have no declared affiliations that could be perceived areas; and covering ears in semirestricted and restricted areas. as posing potential conflicts of interest in the publication of this article. Objectives 1. Discuss practices that could jeopardize safety in the peri- operative area. Sponsorship or Commercial Support 2. Discuss common areas of concern that relate to perioper- No sponsorship or commercial support was received for this ative best practices. article. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Disclaimer Accreditation AORN recognizes these activities as CE for RNs. This AORN is accredited as a provider of continuing nursing ed- recognition does not imply that AORN or the American ucation by the American Nurses Credentialing Center’s Nurses Credentialing Center approves or endorses products Commission on Accreditation. mentioned in the activity. http://dx.doi.org/10.1016/j.aorn.2015.06.002 ª AORN, Inc, 2015 www.aornjournal.org AORN Journal j 299 CLINICAL ISSUES 1.7 www.aorn.org/CE THIS MONTH Surgical wound classification Key words: wound classification, documentation, surgical site infection. Storing and using small, prefilled containers of formalin in the OR Key words: formalin, formaldehyde, eyewash stations, Occupational Safety and Health Administration. Latex-free environments for tissue recovery and organ procurement procedures Key words: allografts, organ donation, tissue recovery, latex sensitivity, latex-free environment. Covering facial hair in semirestricted and restricted areas Key words: facial hair, beards, surgical masks. Covering ears in semirestricted and restricted areas Key words: ears, pierced earrings, surgical head coverings. Surgical wound classification QUESTION: ANSWER: We are having disagreements at our facility about how Perioperative RNs should assign surgical wound classifica- certain procedures should be classified when using the tion collaboratively with the surgeon after a careful assess- Centers for Disease Control and Prevention (CDC) sur- ment of the specific factors associated with each surgical gical wound classification system. Can you discuss the procedure. According to the CDC, surgical wounds should wound classifications that should be assigned to some be classified based on the likelihood and degree of wound common procedures? contamination at the time of surgery.1 The following are 300 j AORN Journal www.aornjournal.org September 2015, Vol. 102, No. 3 Clinical Issues FPO = print & web 4C Figure 1. Surgical Wound Classification Decision Tree. the CDC’sdefinitions of the four surgical wound closed, and if necessary, drained with closed drainage [eg, bulb classifications: drain]. Operative incisional wounds that follow non- penetrating (blunt) trauma should be included in this category [Class I] Clean wounds: These are uninfected operative if they meet the criteria. wounds in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts [Class II] Clean-contaminated wounds: These are operative are not entered. In addition, clean wounds are primarily wounds in which the respiratory, alimentary, genital, or www.aornjournal.org AORN Journal j 301 Van WicklindBrubaker September 2015, Vol. 102, No. 3 Table 1. Wound Classifications for Specific Procedures Cesarean section with long labor or ruptured membranes A cesarean section should be classified as Class II (clean-contaminated) because the uterus is entered to deliver the child. Cesarean deliveries with or without ruptured membranes or long labors are Class II procedures unless there is a specific reason (eg, presence of meconium representing spillage from the fetal gastrointestinal [GI] tract) to assign a Class III (contaminated) rating. Class IV (dirty or infected) would be assigned if an existing clinical infection were present, evidenced by the presence of purulence. Circumcision A circumcision does not enter the genitourinary (GU) tract; therefore, the wound classification should be Class I (clean). Coronary artery bypass grafting Coronary artery bypass grafting does not enter the respiratory tract and should be classified as Class I (clean). Hepatectomy Within the liver is a network of fine tubular channels known as bile capillaries that collect and carry bile. These capillaries merge to form the bile ducts and eventually become the hepatic duct; therefore, a procedure where the liver is completely or partially removed transects the biliary tract, which is a part of the GI tract, and should be classified as Class II (clean-contaminated). Laparoscopic Nissen fundoplication with esophagogastroduodenoscopy In a laparoscopic Nissen fundoplication, the upper curvature of the stomach is wrapped around the esophagus and sutured into place. If the patient has a hiatal hernia, this is also repaired. The GI tract is not entered. For this reason, a laparoscopic Nissen fundoplication is a Class I (clean) procedure. There is no classification for the esophagogastroduodenoscopy because there is no surgical wound. Orchiectomy An orchiectomy procedure should be classified as Class II (clean-contaminated) because the spermatic cord is severed. Orchiopexy An orchiopexy procedure enters the inguinal canal but not the GU tract. It should be classified as Class I (clean). Pancreatectomy The pancreas is part of the GI tract; therefore, a procedure in which the pancreas is completely or partially removed should be classified as Class II (clean-contaminated). Parotidectomy The salivary glands (parotid, submandibular, sublingual) produce saliva and are part of the GI tract. For this reason, surgical procedures involving the salivary glands should be classified as Class II (clean-contaminated). Penile prosthesis A procedure in which a penile prosthesis is inserted enters the erection chambers but not the GU tract. For this reason, it should be classified as Class I (clean). Penrose drain A surgical wound that is closed with a Penrose drain should be classified as Class III (contaminated). According to the CDC, “clean wounds are primarily closed, and if necessary, drained with closed drainage.”1(p109) A Penrose drain is a form of open drainage; therefore, a procedure in which a Penrose drain is placed cannot be classified as Class I. Class II (clean-contaminated) procedures are those where the respiratory, GI, or GU tracts are entered; unless these tracts are entered, the procedure cannot be classified as Class II. The definition of a Class III (contaminated) procedure includes an “open, fresh wound.”1(p109) When a Penrose drain is placed and the surgical wound is closed, the portion of the incision where the drain is inserted remains partially open. This fresh, open wound increases the potential for postoperative infection, so Class III is the correct classification. If the drainage from the wound is purulent, it is Class IV (dirty or infected). Pilonidal cyst If no inflammation or infection is present, the excision of a pilonidal cyst should be classified as Class I (clean). If acute inflammation is present, it should be classified as Class III (contaminated); if existing clinical infection (ie, purulence) is present, it should be classified as Class IV (dirty or infected). Portacaval shunt In this procedure, the hepatic vein is connected to the inferior vena cava. The GI tract is not entered. For this reason, a portacaval shunt should be classified as Class I (clean). Thoracoscopy and thoracotomy When thoracoscopy and thoracotomy procedures are performed, the pleural space is entered but the respiratory tract is not entered. These procedures should be classified as Class I (clean). Vasectomy During a vasectomy, the vas deferens, a part of the GU tract, is severed. For this reason, a vasectomy should