Surgical Site Infection Confusion

Roy H. Constantine  PA-C, MPH, PhD, FCCM, DFAAPA

Former CSPS Representative and Chair

Article originally printed in Sutureline: Jan/Feb 2015 pp. 4-5

Surgical Wound Classifications

Wounds are divided into 4 classes:

  • Class I / Clean: An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tract is not entered.  In addition, clean wounds are primarily closed and, if necessary, drain with closed drainage. Operative incisional wounds that follow non-penetration (blunt) trauma should be included in this category if they meet the criteria.

  • Class II / Clean-Contaminated: An operative wound in which the respiratory alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination.  Specifically, operations involving the biliary tract appendix, vagina and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered.

  • Class III/ Contaminated: Open fresh, accidental wounds. In addition, operation with major breaks in sterile technique or gross spillage from the gastrointestinal tract, and incisions in which acute, non-purulent inflammation is encountered are included in this category.

  • Class IV/ Dirty-Infected: Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforate viscera.  This definition suggests that the organisms causing post-operative infection were present in the operative field before the operation (Mangram et. al., 1999).

Speicher et. al. (2014) notes that surgical site infections (SSI) are a major source of patient morbidity.  A study by Speicher and colleagues compared a national clinical database and the effect of SSI rates on four major types of hepatobiliary procedures. In this study wound classification did not predict the rate of SSI in hepato-pancreatico-biliary surgery. “1% of pancreaticoduodenectomies and 5% of liver resections involving a concomitant biliary or bowel procedure were coded as clean cases in the National Surgical Quality Improvement Program (NSQIP).”  

In a recent program at the American Academy of Pediatrics, Dr. Putnam and colleagues presented – “Surgical Debriefing Improves Surgical Wound Classification and Surgical Site Infection Risk-Stratification in Pediatric Appendicitis.” The authors found a 92% discordance between hospital-documented surgical wound classification (SWC) and operative SWC. As part of the debriefing process an educational session was held, but one third of cases were still misclassified as clean or contaminated (Putnam et. al, 2014). These inconsistencies with risk-stratified quality measures can lead to poor outcomes in quality improvement efforts, inter-hospital rating, lower reimbursements and public misperceptions regarding quality of care (Levy et. al, 2013).

Can bundling processes improve overall outcomes?  One initiative is the New York State Partnership for Patients Advanced Colon Surgery Bundle, which includes the following elements:

Normothermia – Maintain core temperature > 36 C° during the perioperative period

Glucose Control – Maintain blood glucose level < 200 mg/dl on the day of surgery and through the postoperative period

Antimicrobial Prophylaxis – Maintain therapeutic levels of the prophylactic antimicrobial agent in serum and tissues throughout the operation, using weight-based dosing and re-dosing, as appropriate

Increased peri-operative Oxygenation – Maintain optimal tissue oxygenation throughout the peri-operative period by administering supplemental oxygen intra-operatively and post-operatively

Skin Preparation – Use an antiseptic agent with alcohol for skin preparation, unless contraindicated

Clean Standardized Fascia Close – Change gown, gloves, and surgical instruments for closure of fascia

Wound Management – Standardize wound management strategy for all types of colorectal surgeries

But with enhanced protocols (eg.- Colorectal Surgery Enhanced Recovery Protocol - ERP) can further confusion occur as we try to improve patient outcomes and decrease length of stay with new evidence-based approaches?

Criterions of surgical site infections are broken down into Deep Incisional Primary and Secondary (DIP / DIS), Organ Space and Superficial Incisional Surgical Site Infections.  The National Healthcare Safety Network (NHSN) (CDC, 2014) expanded SSI reporting time frames to 30-90 days. Further changes have been made for CDC/ NHSN specific types of infections in 2015 (CDC, 2015).  The Surgical Site Infection Protocol for Substantive Changes has made recommendations that further align with Infection Prevention Organizations (e.g.- Centers for Disease Control and Prevention (CDC), Association of perioperative Registered Nurses (AORN), the American College of Surgeons  (ACS), the Society of Thoracic Surgeons (STS), the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Orthopedic Surgeons (AAOS)).

Infection Present at the Time of Surgery, termed as PATOS (a new quality indicator), is evidence of infection that must be found pre-operatively.  Inter-operative intra-abdominal abscesses would meet this criterion. A patient that had an intra-abdominal abscess, but comes back with a subcutaneous wound infection would not meet this criterion, because the infection was not in the wound in the original procedure. In another example, a person that has no intra-abdominal infection, but who had bowel nicked and now comes in with an intra-abdominal process would not meet this measure.  Examples of this measure are being applied to other body systems as well (CDC, 2015).

The accuracy of data collection is extremely important.  Standardization of quality metrics reporting has been an initiative of NSQIP.  Perceived performance can be influenced by variations in definition and collection methodologies.  

Continued efforts to enhance SSI outcomes are being made with the Joint Commission’s Center for Transforming Healthcare and the American College of Surgeons (ACS).  NSQIP data is regarded as clinically valid. With or without data discrepancies SSI is still one of the most prevalent negative outcomes (TJC). A continued performance improvement process that evaluates patient risk factors must be validated to reduce surgical wound infections. This means that every member of the interdisciplinary team needs to be actively involved in the process, especially when a multidisciplinary approach is required to treat patients. This starts with strong shared decision making processes. The patient and family members (patient-centric process) need to be actively engaged.  AskMe 3 and Teach Back can be implemented. The use of a checklist can be incorporated into the Booking Sheet, the PreSurgical Testing Process, and the admission to the Ambulatory or Surgical Holding area, the Huddle, the Timeout and the Debrief.

As surgical physician assistants we need to have a better understanding regarding SSIs, because a great deal of confusion on best practice, scoring and the way we report outcomes still exists.  Active participation in an Infection Prevention and Control Committee is essential. The Surgical Physician Assistant is a key stakeholder in the development and implementation of organizational safety initiatives. There is no excuse – WE ALL NEED TO BE INVOLVED!!!



  1. Advanced Colon Surgery Bundle Resource Guide. Retrieved on December 31, 2014 from
  2. CDC – National Healthcare Safety Network (NHSN) – Surgical Site Infections Protocol Changes for 2015. Retrieved on 1/2/2015 from
  3. CDC – Surveillance Definition 2014 (Superficial Incisional, Deep Incisional, or Organ / Space.  Retrieved on Janarn 2, 2015 from
  4. CDC / NHSN – Surveillance Definitions for Specific Types of Infections 2015. Retrieved on January 2, 2015 from
  5. Lew SM, Holzmann-Pazqal G, Lally KP, Kaos LS, Tsao K. Quality Check of a quality Measure: Surgical Wound Classification Discrepancies Impact Risk-Stratified Surgical Site Infection Rates in Pediatric Appendicitis. J Am Coll Surg. 2013 Dec; 217(6):969-73
  6. Mangram H, Pearson etl al. Guidelines for Prevention of Surgical Site Infection. American Journal  of Infection Control. 1999; 27(2):97-134
  7. Putnam LR, Levey SM, Holtzmann-Pasgal G, Lally KP, Kao LS & Tsao KJ. Surgical Debriefing Improves Surgical Wound Classification and Surgical Site Infection Risk-Stratification in Pediatric Appendicitis, October 11 2014 (San Diego Marquies) Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, TX
  8. Reducing Colorectal Surgical Site Infections – The Center for Transforming Health Care. Retrieved on December 31, 2014 from
  9. Speicher PJ, Nussbaum  DP, Scarborough JE, Zani S, White RR, Blazer DG, Mantyh CR, Tyler, DS & Clary BM. Wound Classification Reporting in HPB surgery: Can a Single Word Change Public Perception of Institutional Performance. HPB 2014, 16, 1068-1073. Retrieved on December 31, 2014 from