Wound Classification System Research Articles

An Evaluation of Surgical Site Infections by Wound Classification System Using the ACS-NSQIP

Surgical wound classification has been the foundation for infectious risk assessment, perioperative protocol development, and surgical decision-making. The wound classification system categorizes all surgeries into: clean, clean/contaminated, contaminated, and dirty, with estimated postoperative rates of surgical site infection (SSI) being 1%-5%, 3%-11%, 10%-17%, and over 27%, respectively. The present study evaluates the associated rates of the SSI by wound classification using a large risk adjusted surgical patient database. A cross-sectional study was performed using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset between 2005 and 2008. All surgical cases that specified a wound class were included in our analysis. Patient demographics, hospital length of stay, preoperative risk factors, co-morbidities, and complication rates were compared across the different wound class categories. Surgical site infection rates for superficial, deep incisional, and organ/space infections were analyzed among the four wound classifications using multivariate logistic regression. A total of 634,426 cases were analyzed. From this sample, 49.7% were classified as clean, 35.0% clean/contaminated, 8.56% contaminated, and 6.7% dirty. When stratifying by wound classification, the clean, clean/contaminated, contaminated, and dirty wound classifications had superficial SSI rates of 1.76%, 3.94%, 4.75%, and 5.16%, respectively. The rates of deep incisional infections were 0.54%, 0.86%, 1.31%, and 2.1%. The rates for organ/space infection were 0.28%, 1.87%, 2.55%, and 4.54%. Using ACS-NSQIP data, the present study demonstrates substantially lower rates of surgical site infections in the contaminated and dirty wound classifications than previously reported in the literature.

The Role of Platelet-Rich Plasma in Inguinal Wound Healing in Vascular Surgery Patients

The objective was to determine whether incision application of platelet-rich plasma (PRP) will decrease postoperative wound complications in vascular surgery patients. A prospective, randomized trial randomized 81 incisions in 51 patients who underwent femoral artery exposure for elective revascularization procedures or endovascular abdominal aneurysm repairs. Incidence of diabetes, chronic renal failure, prosthetic grafts, body mass index (BMI), and steroid use did not differ. Using the ASEPSIS wound classification system, we found no difference in incidence of wound infection. Wound complications occurred in 9 (23%) of 40 of PRP group and 9 (22%) of 41 of non-PRP. Severe wound complications developed in 5 (13%) PRP and 6 (5%) of non-PRP (P = NS). In multivariate analysis, there were no predictors for wound infection. Groin wound complications rates are common in this patient group. Platelet-rich plasma did not decrease the incidence of groin wound complications in our patients.

Quality of life in patients with diabetic foot ulcers: validation of the Cardiff Wound Impact Schedule in a Canadian population

The purpose of this study was to evaluate and validate the Cardiff Wound Impact Schedule (CWIS), a disease-specific quality-of-life measure, in a diabetic foot ulcer (DFU) population. Patients with DFUs have restrictions as part of their treatment and rehabilitation, which can affect health-related quality of life (HRQoL). Because of the high number of comorbidities experienced in diabetes, a disease-specific quality-of-life measure is needed to best assess the affect of a foot ulcer on HRQoL. Patients with DFUs completed the CWIS and a World Health Organization generic quality-of-life questionnaire. Validity was assessed by comparing domains of the questionnaires. Patients were categorised using the University of Texas wound classification system. Mean CWIS scores were compared between categories to assess the questionnaire's ability to differentiate wound severity. Patients with open ulcers scored significantly lower on the CWIS than those with healed ulcers. Correlations between questionnaire domains were as follows: Social Life with Social Functioning (r = 0·641, P < 0·001); Well-Being with General Health (r = 0·533, P < 0·01); Physical Symptoms and Daily Living with Physical Functioning (r = 0·631, P < 0·01) and Health-Related Quality of Life with Vitality (r = 0·425, P < 0·01). However, there was no significant difference in mean CWIS scores between categories of wound severity. We have demonstrated the ability of the CWIS in assessing HRQoL in a DFU population and its ability to differentiate between healed and non healed states.

Thoracoabdominal shotgun wounds: an evaluation of factors associated with the need for surgical intervention

Background Shotgun wound classification systems attempt to predict the need for surgical intervention based on the size of wounds, pellet spread, or distance from the weapon rather than clinical findings. Methods A 5-year retrospective review of patients sustaining a thoracoabdominal shotgun wound was performed. Factors believed to be associated with the need for surgical intervention were examined using the Fisher exact test or an independent sample t test. Results Sixty-four patients suffered a thoracoabdominal shotgun wound. Fifty-nine percent required surgical intervention. Factors significantly associated with the need for surgical intervention were a low revised trauma score and systolic and diastolic blood pressure ( P < .05). Distance from attacker, wound patterns, pellet size, and pellet spread were not found to have an association. Conclusions Clinical indicators of hemorrhage and shock are associated with the need for surgical intervention, whereas pellet spread, pellet size, and distance from the attacker are not. This is a significant departure from traditional classification systems.

Clinical outcomes of diabetic foot management with Circulat

Major and minor lower-extremity amputation is a common complication among diabetics. Various sources indicate diabetic foot ulcer prevalence at between 2.2% and 15% in diabetics. This study evaluates the efficacy and tolerance of a standardized plant extract combination, Circulat, developed for the prevention and treatment of severe manifestations of type 2 diabetes, such as necrotic damage of the foot. Thus, a retrospective cohort study was carried out in 174 patients treated with Circulat with diabetic foot grades D1-D3, according to The University of Texas Wound Classification System, in 50 medical centers, from 2004 to 2007. Circulat obtained 50.57% complete cure of diabetic foot, significant improvement in 37.9% and prevented amputation in 88.5% of the study's total population. The treatment was well tolerated. Four patients (2.3%) had slight gastrointestinal unrest which did not warrant suspension of treatment.

Botulinum toxin A for the treatment of ulcer caused by oro-mandibular dyskinesia in a patient with a vegetative state

Background: The number of botulinum toxin applications is expanding, as evidenced by the studies that demonstrate its new therapeutic indications. Botulinum toxin type A (BoNT-A) alone or adjunct to other agents has emerged as a new important therapeutic strategy for clinicians treating a wide range of neurological and not-neurological disturbances, and it may result useful for particular clinical pictures. Case description: A 73 year-old male subject had a severe sub-arachnoid hemorrhage following the rupture of a giant aneurism of the middle left cerebral artery. Its clinical features showed quadriplegia, vegetative state and oro-mandibular dyskinesia. The dyskinetic repetitive disorder produced a chronic ulcer on the lower lip. The ulcer had slightly irregular borders and resulted stage II–III according to the European Pressure Ulcer Advisory Panel wound classification system. Because of dyskinetic movement disorder, all efforts to heal the ulcer by topical medication were vanished. The upper and lower orbicularis oris and masseter muscles with a total of 320 units per single session botulinum toxin type A (BoNT-A) (Dysport® Ipsen) were injected. The treatment reduced the sucking and forced jawing and promoted the care of ulcer, which after 3 months from the initial infiltration healed completely. Outcome and discussion: The vegetative state can represent a dramatic neurological sequel of extensive brain tissue damage. The rehabilitation process of these patients involves all clinicians, nurses and caregivers in several complex and challenging tasks. BoNT-A infiltration reduced oro-mandibular dyskynesia and weakened orbicularis oris muscle and repetitive sucking hallowing topical medication and the ulcer healing. It has been suggested that the use of BoNT-A as adjunct to other interventions may represent an important therapeutic aid for the clinicians treating rare pathological conditions that otherwise result untreatable.

A Comparative Study of the Use of Exsikines and Other Advanced Wound Care Products/Modalities in the Treatment of Various Wound Types in Efficacy

To examine the efficacy of Exsikines (patent-pending) in the treatment of chronic wounds. Subjects were treated with Exsikines every 3 to 5 days, wound healing parameters were monitored and compared with other published studies. A clinical practice. A total of 21 patients (22 chronic wounds each identified etiologically) were randomly selected for this study, based on presentation of Stage II or III wounds using the Wagner wound classification system of at least 6 weeks' duration. The average wound age in this study was 12.48 months with a median wound age of 3 months. To reflect clinical practice scenarios, no other criteria for inclusion were required. The study was initiated with 24 patients with 24 chronic wounds. Three patients were removed from the study for nonadherence of the therapeutic protocol of Exsikines application. Baseline measurements were taken of all wounds, and time of persistence was noted. Exsikines, a patent-pending mixture of homologous-derived blood products containing human cytokines and other growth factors, was applied to the wounds at approximately 4-day intervals. Wound measurements were taken intermittently. Healing times, healing rates, recurrence rates, cost of treatments, and other parameters were determined. One hundred percent of the wounds were completely healed within an average of 53.5 days (median, 41.5 days). Recurrence monitoring after wound closure averaged 8.9 months. Recurrence in diabetic ulcers and pressure ulcers occurred at a rate of 7.14% and 16.67%, respectively. Wounds were documented by digital photography. In comparison to standard wound care, as well as other wound care products, Exsikines offers a very efficacious method of treating chronic wounds.

Wundinfektionen in der Viszeralchirurgie - Ätiologie, Risikofaktoren, Antibiotikaprophylaxe

Nosocomial infections are the major cause for morbidity and mortality in hospital. In Germany 3.5 % of patients developed nosocomial infections, 15 % of these are wound infections post surgery. Asepsis, proper surgical technique and identifying patients at risk of infections and antibiotic prophylaxis are the most effective measures to reduce postoperative wound infection rate. To identify patients at risk by traditional wound classification system alone seems to be insufficient. Risk factors others than the suspected contamination rate at the end of the operation have to be detected. Indication, choice of the antibiotic agent and timing of antibiotic prophylaxis will be discussed.

Extremitätenerhalt für den diabetischen Fuß

Lower-extremity amputation (LEA) is a common complication among patients with diabetes. This study tests the effects of a structured disease management program for the diabetic foot (DF) aiming to reduce the number of LEA. DESIGN, METHODS: In a prospective study design we investigate patients with DF in a system of outpatient treatment, acute in-patient care and rehabilitative treatment. Subjects were recruited since January 1(st), 2000, with the latest admission being December 31, 2004. All study participants undergo a five-year follow-up observation period. The University of Texas Wound Classification System (UT) of foot ulcers serves as basis of the documentation and analysis. We evaluated numbers of LEA, rates of ulcer healing and underlying forms of peripheral vascular disease. We report the results of the first patient group completing the two-year follow-up examination. In 2000, 102 subjects with new foot ulcers were consecutively included into the study. 68.6% were men, the mean age of the study population was 68.1 +/- 11.4 years and the mean diabetes duration was 19.4 +/- 10.3 years. After two years, 68 patients can still be examined. Altogether, 22 patients (21.6%) died, and 12 (11.8%) dropped out for various reasons. At the point of discharge from the clinics 35.3% of the ulcers had healed and another 44.1% were in UT grade 1. After two years, a complete healing could still be determined with 51 patients (50.0% of the cohort of the original 102 patients, or 75.0% of the subjects reaching the two-year follow-up). 10 subjects (9.8% or 14.5%) were in the UT grade 1. Eight diabetics underwent major amputation (MA) during the two-year examination period (amputation rate 7.8%). The primary objective of the study, a significant reduction of MA with DF patients, has been achieved. The ulcer healing rates are comparable to the reports of leading centers.

Diabetic foot infections: an audit of antibiotic prescribing in a diabetic foot clinic

AbstractInfected diabetic foot ulcers cause substantial morbidity and mortality. Antibiotic therapy is necessary for all infected ulcers but widespread antibiotic prescription can lead to adverse effects and increased resistance. The main purpose of this audit was to survey our antibiotic prescription pattern and to assess the appropriateness of prescriptions in the diabetic foot clinic.We graded 85 consecutive wounds seen in the clinic using the University of Texas Wound Classification System (UTWCS). This system allows ulcers to be classified according to depth, presence of infection and ischaemia.We found that 55 wounds (65%) were infected and antibiotics were prescribed for 51 wounds (93%). Four infected wounds did not have antibiotics prescribed. Four patients (7%) with infected ulcers required admission for intravenous antibiotic treatment. All four had deep infections involving bone. Deep wound swabs were performed on 52 of the infected wounds and three (6%) grew methicillin‐resistant Staphylococcus aureus. The antibiotics commonly used were cefradine, clindamycin, and combinations of clindamycin + ciprofloxacin or amoxicillin + flucloxacillin. In the remaining 30 uninfected wounds (35%), no antibiotics were prescribed.In the foot clinic, antibiotic prescription was generally appropriate but not all patients with infected ulcers received antibiotic therapy. As a result of this audit, we have devised a simple antibiotic protocol in an attempt to improve the management of infected diabetic wounds in a safe, methodical and effective manner. Copyright © 2006 John Wiley &amp; Sons.

The Efficacy of Hyperbaric Oxygen Therapy in Improving the Quality of Life in Patients With Problem Wounds

The unpredictable course followed by severe, chronic, non-healing wounds not only restricts the daily activities of affected patients, but also impairs their quality of life (QOL). Hyperbaric oxygen therapy (HBOT) treatment for such wounds elevates tissue oxygen content, increases cellular repair functions and the probability of wound healing, and improves the patient's QOL. This was a longitudinal, prospective study, and used a purposive sampling method. A total of 15 patients receiving HBOT at a medical center were enrolled. Data were collected by questionnaire before and after HBOT. The questionnaire included basic patient characteristics, self-perceived wound severity, wound physiological indices, and a QOL scale. The overall QOL score of the subjects after HBOT was higher than before HBOT. After HBOT, there was a positive correlation between the QOL of patients with problem wounds and the scoring of the Strauss wound classification system. After HBOT, there was a negative correlation between the QOL of patients with problem wounds and their self-perceived severity of the wound. The results were then used to provide suggestions for nursing care and additional research directions in order to effectively assist patients with problem wounds receiving HBOT, with the goal of achieving an optimal QOL.

Expression of matrix metalloproteinases and growth factors in diabetic foot wounds treated with a protease absorbent dressing

Wound healing in diabetes is impaired, and nonhealing ulceration represent clinically relevant complications. Persistently high levels of matrix metalloproteases (MMPs) contribute to wound chronicity. Thus, the topical use of protease inhibitors might influence wound healing and promote transition from a chronic to an acute wound. Methods In this study, 33 patients with chronic diabetic foot lesions (stage 2a of the University of Texas Wound Classification system) were included. Fifteen patients received redundant “good standard wound care.” In addition, 18 patients were treated with a protease inhibitory modulating matrix (the OCR/collagen Promogran matrix, Ethicon) with dressings changed on a daily basis. Prior to treatment and at 4 and 8 days after treatment, two 3-mm punch biopsies were taken from the center of the wounds and analyzed using ELISA techniques for MMPs, tissue inhibitor of MMP-2 (TIMP-2), and interleukin-1β (IL-1β) levels. In addition, mRNA levels of MMPs as well as IL-1β and TNF-α were detected using quantitative real-time polymerase chain reaction (TaqMan, Applied Biosystems, Weiterstadt, Germany). Results No differences were detected between both groups and at the three time points for the mRNA levels of MMPs as well as of IL-1β and TNF-α. In addition, MMP levels in wound tissue (analyzed by ELISA) were also not significantly different between both groups. However, IL-1β was increased on day 8 in the treatment group ( P=.01) only. Interestingly, we found a significant reduction of the MMP-9/TIMP-2 ratio in the group being treated with the ORC/collagen. These wounds exhibited a more rapid healing rate when treated with the ORC/collagen matrix. Conclusions The local treatment with a protease inhibitor has a beneficial effect on wound healing. In contrast to the data on wound fluid, our study demonstrated for the first time the unaltered mRNA levels of MMPs during treatment with a protease inhibitory modulating matrix. At the cellular level, MMPs were also not statistically different. However, the more relevant ratio of MMP-9/TIMP-2 was decreased in the treatment group. An equally important finding was that we did not detect a compensatory increase in the MMP-RNA expression even though wound size was clearly reduced.

Wound Healing

Wound healing in orthopaedic care is affected by the causes of the wound, as well as concomitant therapies used to repair musculoskeletal structures. Promoting the health of the host and creating an environment to foster natural healing processes is essential for helping to restore skin integrity. Normal wound healing physiologic processes, factors affecting wound healing, wound classification systems, unique characteristics of orthopaedic wounds, wound contamination and drainage characteristics, and potential complications are important to understand in anticipation of patient needs. Accurate wound assessment and knowledge of nursing implications with specific wound care measures (cleansing, debridement, and dressings) is important for quality care. New technologies are enhancing traditional wound care measures with goals of effective comfortable wound care to promote restoration of skin integrity.

Use of pressure reducing seats and cushions in a community setting.

It is generally accepted that sitting for long periods of time without frequent repositioning or provision of appropriate cushions or chairs can lead to pressure ulcer development in people who are elderly, frail, immobile or neurologically impaired. When sitting, in comparison to lying, only a small surface area of the body is providing support, predominantly the buttocks and thighs, and the feet. Therefore, interface pressures are much greater in sitting than lying. Sitting for long periods of time can result in the person adopting poor posture, which in turn can lead to the development of pressure ulcers, particularly on the buttocks, sacrum, greater trochanter and heels. Assessment and provision of appropriate seating equipment for people at risk is often difficult for clinicians working in the community. This article aims to describe the problems experienced by people who sit for long periods of time, to discuss where people should go in order to obtain help with seating needs, and outline some of the potential solutions to poor seating which are available to community staff.

Total contact casts were better than removable cast walkers or half shoes for healing diabetic neuropathic foot ulcers

Armstrong DG, Nguyen HC, Lavery LA, et al. Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care2001 Jun; 24 : 1019 –22 [OpenUrl][1][Abstract/FREE Full Text][2] QUESTION: In patients...

Classification of wounds of the diabetic foot.

A classification system should be thought of as a diagnostic language. Ideally, this language should be used by a large, diverse population of clinicians to guide therapy and ultimately predict outcome. The diabetic foot ulcer is widely known to be the prime precipitant of lower extremity amputations. Its description and classification is the first step toward widespread standardization of treatment and prevention. This article chronologically describes the major diabetic foot wound classification systems devised over the previous generation, discussing each of their attributes and their shortcomings, with an emphasis on an evidence basis for care. It is our hope that discussions such as this one will ultimately lead to a diagnostic and therapeutic lingua franca for diabetic foot wounds and a commensurate reduction in the unconscionably high prevalence of amputations, which we now currently face.

Prophylactic antibiotics are not indicated in clean general surgery cases

Background: In assigning risk of infection, the traditional wound classification system has been replaced by the National Nosocomial Infection Surveillance (NNIS) system. NNIS classification is determined by procedure length, wound cleanliness, and ASA status. To date, no prophylactic antibiotic guidelines have been proposed for the NNIS system. Methods: Clean general surgery cases were retrospectively reviewed in our hospital for infection and prophylactic antibiotic use. These cases were then stratified per the NNIS system. Results: One thousand twenty-three clean general surgery cases had 16 (1%) surgical site infections. The infection rate in NNIS class 0, 1, and 2 cases not given prophylactic antibiotics was 1.21%, 3.03%, and 0%, respectively. The infection rate in NNIS class 0, 1, and 2 cases given prophylactic antibiotics was 0.94%, 2.44%, and 6.67%, respectively. Conclusions: No statistically significant decrease in infection rate was demonstrated by us using prophylactic antibiotics, regardless of the NNIS classification in clean general surgery cases.

Standardized infection ratio: the next generation of risk-adjusted wound infection measures

Abstract Background The scientific literature overwhelmingly supports the value of surgical site infection (SSI) surveillance with feedback of infection rates to surgeons. Recognizing that feedback has little value without some form of adjustment for patient factors, surgeons long ago developed the four-level wound classification system. In the 1980s the SENIC multivariate risk index was introduced, followed by the National Nosocomial Infection Surveillance multivariate risk index which is the currently recommended US standard. Methods To address recent advances in surgical technology, ambulatory surgery, and differences between the USA and other countries, newer risk-adjustment methods were explored. The ideal approach would overcome the following common practical problems encountered in generating SSI rates such as: (1) new patient-level risk factors, (2) technology-specific factors, (3) small monthly denominators and (4) postdischarge surveillance. Despite increased mathematical complexity, an acceptable risk-adjustment technique must still provide easily interpretable results. Results The standardized infection ratio (SIR) is proposed as the next generation in epidemiological approaches for monitoring and feeding back risk-adjusted SSI rates to surgeons. The SIR is a single monthly number for each surgeon, calculated by dividing the observed number of SSIs by the expected number predicted from a complex statistical model of patient-level and technology-specific risk factors. Like the well known standardized mortality ratio, the SIR offers the advantage of providing one generalizable quality index regardless of the mix of operations performed. In addition, the SIR is well suited to control chart techniques and for providing valid interhospital comparisons. Conclusion The SIR model offers simple data input and easily interpretable output suitable for application in all healthcare settings worldwide.

Body piercing; perineal preps; insects in the OR; wound classification systems; recommended practices

Body piercing; perineal preps; insects in the OR; wound classification systems; recommended practices

Evaluation of the SENIC Risk Index in a Spanish University Hospital

To assess the performance of the Study of the Efficacy of Nosocomial Infection Control (SENIC) risk index for the evaluation of the risk of surgical-site infection (SSI) in a country other than the United States, having a different health system. 350-bed university hospital in Spain belonging to the National Health System (Insalud). Observational cohort study of 1,019 patients who underwent consecutive surgery from January to December 1992. Surgical-infection risk factors assessed by the traditional wound-classification system (clean, clean-contaminated, contaminated, and dirty-infected wound) and by the SENIC risk index (length of intervention more than 2 hours, more than three discharge diagnoses, abdominal surgery, and contaminated or dirty-infected wound) were compared by forward logistic regression. The SENIC risk index showed a greater ability to predict SSI than the traditional wound-classification system. The study carried out in our institution reproduced the estimators provided by the SENIC study in the United States. The SENIC risk index provided a stepwise increase in SSI rates, according to the number of factors present, for every traditional wound-classification group. In the case of clean wounds, the incidence of surgical infection (per 100 interventions) increased (1.5, 2.4, 5.3, and 50; P<.001) for patients having from zero to three risk factors of the SENIC risk index. This study shows that the SENIC risk index results are reproducible, and the index can be used to compare rates of wound infection across countries with different health systems than the United States.