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How is the surgical wound classification determined?  

What is the purpose of documenting surgical wound classifications?   

What is the correct procedure for receiving verbal medication orders in the perioperative setting?  

What are the surgical wound classifications?   

Who is authorized to receive and record verbal orders in the perioperative setting?  

Does the count sheet need to be kept in the patient's record or retained for a set amount of time? 


How is the surgical wound classification determined?

Answer: 

Surgical wound classification is determined using the wound classification scheme from the CDC described below. AORN has developed the Surgical Wound Classification Decision Tree to assist in decision making for surgical wound classification.  Perioperative nurses can use the Surgical Wound Classification Decision Tree as a tool to assist in decision making for surgical wound classification. The wound classification is subject to change; therefore, the wound classification should be assigned in consultation with the surgeon at the end of the procedure and documented in the perioperative record.

Resources 

  1. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013;331-364.
  2. Van Wicklin S. CDC surgical wound classification system/Surgical wound classification decision tree [Clinical Issues]. AORN J. 2012.
  3. Mangram AJ , Horan TC , Pearson ML , Silver LC .Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;27(2):97-132.
  4. Howard JM, Barker WF, Culbertson WR, et al. Postoperative wound infections: The influence of ultraviolet irradiation of the operating room and various other factors . Ann Surg. 1964;160(Suppl 2):1–192.
  5. Simmons BP. Guideline for prevention of surgical wound infections. Infect Control. 1982;3:185-196.

Updated January 28, 2013

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What is the purpose of documenting surgical wound classifications?

Answer:

The wound classification is a formula used for grading the extent of microbial contamination postoperatively, thereby indicating the likelihood that a patient will develop an infection at the surgical site. The classification also allows for comparison of wound infection rates associated with different surgical techniques, surgeons and facilities. The comparison may be useful for research and may also serve to alert infection prevention personnel to wounds at increased risk for infection, enabling appropriate surveillance and preventative measures to be taken.

Resources 

  1. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013;331-364.
  2. Van Wicklin S. CDC surgical wound classification system/Surgical wound classification decision tree [Clinical Issues]. AORN J. 2012.
  3. Mangram AJ , Horan TC , Pearson ML , Silver LC .Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;27(2):97-132.
  4. Howard JM, Barker WF, Culbertson WR, et al. Postoperative wound infections: The influence of ultraviolet irradiation of the operating room and various other factors . Ann Surg. 1964;160(Suppl 2):1–192.
  5. Simmons BP. Guideline for prevention of surgical wound infections. Infect Control. 1982;3:185-196.

Updated January 28, 2013

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What is the correct procedure for receiving verbal medication orders in the perioperative setting?

Answer:

The National Coordinating Council for Medication Error Reporting and Prevention recommends that all verbal orders be converted to written orders and signed by the individual receiving the order. Verbal orders should be documented in the patient's medical record and reviewed and countersigned by the prescriber as soon as possible. Record the order on either the regular physician's order form or perioperative record according to facility policy and procedure.

The following steps can be taken to guide safe medication practices when taking verbal orders:
     •Develop a read-back system that includes verbalizing the read-back digit-by-digit (eg, one-five, not fifteen)
     •Allow only licensed health care providers to receive verbal orders
     •Consider using a visual tool to enhance communication (ie, dry erase board)
     •Limit distractions and interruptions
     •Record the order on the patient medical record as soon as possible
     •Question prescribers when there are any concerns or clarification is needed about verbal orders 

Resources 

  1. Recommended practices for medication safety. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013;255-294.
  2. Recommendations to reduce medication errors associated with verbal medication orders and prescriptions, February 24, 2006. National Coordinating Council for Medication Error Reporting and Prevention. http://www.nccmerp.org/council/council2001-02-20.html. Accessed November 20, 2012.
  3. Hendricksen T. Verbal medication orders in the OR. AORN J. 2007;86(4):626-629.
  4. Record of care, treatment, and services. In: Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations;2010:RC-1-RC-13.

Updated January 28, 2013 

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What are the surgical wound classifications?

Answer: 

The Center for Disease Control and Prevention uses an adaptation of the American College of Surgeons wound classification schema, which divides surgical wounds into four classes:

     •CLASS I/CLEAN WOUNDS—an uninfected surgical wound in which no inflammation is encountered and the respiratory, alimentary, genital, or urinary tracts are not entered. Clean wounds are primarily closed and, if necessary, drained with closed drainage. Surgical wound incisions that are made after nonpenetrating (ie, blunt) trauma should be included in this category if they meet the criteria.

     •CLASS II/CLEAN-CONTAMINATED WOUNDS—a surgical wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically included in this category are surgical procedures involving the biliary tract, appendix, vagina, and oropharynx, provided no evidence of infection is encountered and no major break in technique occurs.

     •CLASS III/CONTAMINATED WOUNDS—open, fresh, accidental wounds. This typically involves surgical procedures in which a major break in sterile technique occurs (eg, emergency open cardiac massage) or when gross spillage from the gastrointestinal tract and incisions in which acute, nonpurulent inflammation is encountered.

     •CLASS IV/DIRTY OR INFECTED WOUNDS—old traumatic wounds with retained or devitalized tissue, as well as wounds that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the wound before the surgical procedure. 

Resources 

  1. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013;331-364.
  2. Van Wicklin S. CDC surgical wound classification system/Surgical wound classification decision tree [Clinical Issues]. AORN J. 2012.
  3. Mangram AJ , Horan TC , Pearson ML , Silver LC .Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;27(2):97-132.
  4. Howard JM, Barker WF, Culbertson WR, et al. Postoperative wound infections: The influence of ultraviolet irradiation of the operating room and various other factors . Ann Surg. 1964;160(Suppl 2):1–192.
  5. Simmons BP. Guideline for prevention of surgical wound infections. Infect Control. 1982;3:185-196.

Updated January 28,  2013

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Who is authorized to receive and record verbal orders in the perioperative setting?

Answer:

Authorization is given according to facility policy and state and federal regulations such as the nurse practice act.  The Joint Commission (JC) and Centers for Medicare and Medicaid Services (CMS) requirements state facility policy and state and federal regulations must be followed regarding who is authorized to receive and record verbal orders.

Resources

  1. Recommended practices for medication safety. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013;255-294.
  2. Recommendations to reduce medication errors associated with verbal medication orders and prescriptions, February 24, 2006. National Coordinating Council for Medication Error Reporting and Prevention. http://www.nccmerp.org/council/council2001-02-20.html. Accessed November 20, 2012.
  3. Hendricksen T. Verbal medication orders in the OR. AORN J. 2007;86(4):626-629.
  4. Record of care, treatment, and services. In: Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations;2010:RC-1-RC-13. 

Updated Januaray 28, 2013

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Does the count sheet need to be kept in the patient's record or retained for a set amount of time? 

Answer:

AORN does not have a recommendation to include count sheets in the patient's record or to retain the sheet for a set amount of time. Count sheets are usually a tool used to facilitate the counting process and instrument inventory. If the health care organization develops a policy for retaining count sheets, the policies should comply with regulatory and accreditation requirements. 
 

Resource

 
Denholm B. Count sheets. [Clinical Issues]. AORN J. 2013;98(1):88-89.
 
Updated August 7, 2013
 

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