Assess For and Mitigate Risk Factors Preoperatively
- Patients should abstain from smoking for at least three weeks pre and postoperatively (Herbert & McCormick, 2006).
- Obese patients should be informed of surgical risk in regards to their weight and be encouraged to lose weight prior to surgery to decrease the risk of wound complications (Lobley, 2013).
- Provide a balanced diet or nutritional support with sufficient protein to achieve positive nitrogen balance. Treat any suspected micronutrients deficiencies, especially Vitamin A, Vitamin C, and zinc (Scholl, 2001).
- Preoperative corticosteroids treatment of at least 30 days, particularly at prednisone doses of 40 mg/day or greater, may increase wound complication rates up to two to five times (Wang, 2013). Evaluate corticosteroid treatment and if appropriate adjust prior to surgery according to medical evaluation.
- Medication with an anticoagulant effect, such as aspirin or non-steroidal anti-inflammatory drugs should be evaluated and adjusted prior to surgery according to medical evaluation (Doughty, 2004).
- Treat preoperative anemia. Lower preoperative hemoglobin has been described as operative risk factors for wound complications (Subramanian et al., 2014).
Prevention of Surgical Site Infections
Safer Healthcare Now! (2014)
Four Key Components of Reliable Perioperative Care:
- Antimicrobial Coverage Peri-operatively.
Appropriate Hair Removal.Maintenance of Perioperative Glucose Control.Perioperative Normothermia.
- Appropriate use of prophylactic antibiotics; and
- Antiseptic prophylaxis.
Detailed information relative to the four key components above is available in the
Safer Healthcare Now! Surgical Site Infection Getting Started Kit (2014).
Mitigate Risk Factors: Perioperative
- Excessive intraoperative blood loss and long surgical duration have been described as operative risk factors for wound complications (Subramanian et al., 2014).
- Subcutaneous closure if the depth is greater than 2 cm is effective to avoid wound complications (Tipton et al., 2011).
- An optimal technique for closure of abdominal surgical wounds includes:
Use of staples for Caesarean delivery closure is associated with an increased risk of wound complications (Basha et al., 2010).Laparoscopic approach is associated with a decreased risk of wound disruption (Moghadamyeghaneh et al., 2014).Various forms of peritoneal lavage are routinely used in the management of patients with peritonitis. With increased use of prophylactic antibiotics, the trend in general surgery has been away from the use of antibiotics in intra-abdominal irrigation however, imipenem 1 mg/ml irrigation (Parcells et al., 2009) and gentamicin-clindamycin irrigation (Ruiz-Tovar et al., 2012) have been found to be associated with a lower incidence of intra-abdominal abscesses and wound infections. Irrigation at the time of Caesarean delivery increases intraoperative nausea without any beneficial effects on postoperative maternal infectious morbidity (Viney et al., 2012).
- Use of a simple running technique.
- Use of #1 or #2 delayed absorbable suture.
- Use of mass closure to incorporate all layers of the abdominal wall (except skin).
- Taking wide tissue bites (about 1 cm).
- Use of a short stitch interval (about 1 cm) (Mizell, 2016).
- Assess and manage pain. The exaggerated release of pain mediators may result in nociceptor hypersensitation, hyperinflammatory cellular and extracellular matrix changes, and in some cases the potential for a fibrotic healing pattern (Widgerow & Kalaria, 2012).
- Educate patients to avoid heavy lifting following abdominal surgery to minimize stress on the healing fascia (Mizell, 2016).
Manage Open Surgical Wounds
(Orsted et al., 2010)
1. Complete a holistic assessment to identify factors that may affect surgical wound healing in the pre-operative, intra-operative and post-operative phases.
2. Create a treatment plan to eliminate or reduce factors that may affect surgical wound healing in the pre-operative, intra-operative and post-operative phases of care.
3. Include the patient, family and/or caregiver as members of the team when developing care plans.
4. Educate the patient, family and/or caregiver to optimize surgical wound healing.
5. Assess the surgical wound and document findings using a standardized approach.
6. Debride the surgical wound of necrotic tissue.
7. Rule out or treat a surgical site infection.
8. Provide optimal local wound moisture balance to promote healing by choosing an appropriate dressing for the acute and chronic phases of surgical wound healing.
9. Determine the effectiveness of interventions and reassess if healing is not occurring at the expected rate. Assess the wound edge and rate of healing to determine if the treatment approach is optimal.
10. Consider the use of adjunctive therapies and biologically active dressings.
11. Recognize that surgical wound healing requires a team approach.
12. Implement a surgical site surveillance program that crosses clinical setting boundaries.
Care of Perineal Obstetric Wound
(Harvey et al., 2015)
- Obstetrical care providers should follow a policy of restricted episiotomy (i.e. perform an episiotomy only if indicated).
- If an episiotomy is indicated, a mediolateral over midline should be considered. The optimal cutting angle appears to be no less than 45 degrees and ideally around 60 degrees.
- Obstetric anal sphincter injuries should be repaired by appropriately trained clinicians. Repairs can be delayed eight to 12 hours, with no detrimental effect, to ensure access to an experienced obstetrical surgeon.
- Prophylactic single dose intravenous antibiotics should be administered for the reduction of perineal wound complications following the repair of obstetrical anal sphincter injury.
- Laxative should be prescribed following an obstetrical anal sphincter injury repair to ensure an earlier and less painful first bowel movement.
Conduct Clinical and System Reviews (see details below)
Given the broad range of potential causes of this clinical group, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.
Clinical and System Reviews, Incident Analyses
Occurrences of harm are often complex with many contributing factors. Organizations need to:
- Measure and monitor the types and frequency of these occurrences.
- Use appropriate analytical methods to understand the contributing factors.
- Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
- Have mechanisms in place to mitigate consequences of harm when it occurs.
To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for analysis methods are included in Resources for Conducting Incident and/or Prospective Analyses section of the Introduction to the Hospital Harm Improvement Resource.
Chart audits are recommended as a means to develop a more in-depth understanding of the care delivered to patients identified by the HHI. Chart audits help identify quality improvement opportunities.
Useful resources for conducting clinical and system reviews: