How to Accurately Identify, Evaluate and Document Surgical Site Wounds

Surgical Site WoundsA surgical wound is caused by a cut or incision made by a surgeon using a scalpel on a patient’s body during a surgery. Usually, these wounds are made in a sterile environment where many variables can be controlled such as bacteria, size, location and the nature of the wound itself. However, there are chances of developing infection at the incision site, when micro-organisms from the skin or the environment enter a patient’s body through the surgical site. Healthcare providers should evaluate the surgical site infection carefully to develop a comprehensive plan of care and determine treatment goals. Efficient wound care consulting services can help with accurate diagnosis, evaluation, and documentation of wounds.

The following are important factors that should be evaluated for surgical site infection cases:

  • Risk factors for delayed healing such as impaired nutritional status, surgery lasting longer than 2 hours and excessive blood loss during surgery, poor mobility and physical activity, advanced age, lifestyle factors, medical conditions, oxygenation status of the skin and underlying tissues as well as medications that interfere with wound healing.
  • Pain
  • Location and length of incision
  • Closure methods, including sutures, staples, tape, steri-strips or tissue adhesive
  • Presence of exudates and description
  • Acute inflammatory response and edema
  • Presence of the healing ridge
  • Signs of internal 2 or external hemorrhage (hematoma) especially for surgery in the post nasal passages, lungs, spleen, liver, stomach & uterus
  • Presence of drains
  • Assessment for wound healing by secondary intention
  • Wound measurements and check for undermining, tunneling or sinus tracts.
  • Wound probing to bone
  • Appearance of wound bed, noting percentage of tissue type
  • Amount and type of exudates
  • Presence of odor, after cleansing
  • Description of wound edge and peri-wound skin
  • All details including SSI signs and symptoms, impact of the wound on the patient’s daily life and body image

These details should be documented efficiently and accurately to improve patient care. With a good wound EMR, healthcare providers can perform the documentation tasks accurately and quickly.

WHO recommends certain effective ways to prevent surgical site infection and related complications. They include:

  • Antibiotics should only be used to prevent infections before and during surgery, not afterwards
  • Antimicrobial sealants should not be used after surgical site skin preparation, instead use alcohol-based antiseptic solutions CHG (chlorhexidine gluconate)
  • People preparing for surgery should always have a bath or shower, but not be shaved
  • For patients undergoing any surgical procedure, hair should either not be removed or, if absolutely necessary, be removed only with a clipper
  • Warming devices should be used in the OR and during the surgical procedure for patient body warming
  • Antibiotic incisional wound irrigation should not be used
  • Prophylactic negative pressure wound therapy can be used in adult patients on primarily closed surgical incisions in high-risk wounds
  • Preoperative antibiotic prophylaxis should not be continued in the presence of a wound drain

By following these recommendations surgical teams in hospitals, clinics, and other wound care organizations can reduce the chances of wound infection to a great extent.