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Hospital Harm: Wound Disruption

Wound healing is a critical outcome in surgery, and postoperative wound disruption is a serious complication. Surgical incisions are acute wounds that activate the healing process.

Topics
  • Patient safety
  • Hospital harm
Audience

  • Point of care provider

  • Quality or safety improvement lead

  • Policy advisor or analyst

Goal

Reduce the incidence of wound disruption in surgical and obstetrical patients by assessing risk, implementing risk factor modifications prior to surgery and instituting good wound care management.

Overview

Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.

The healing process has four identified stages, namely: coagulation, inflammation, proliferative phase/granulation tissue formation and the remodeling phase, in reality it is a complex, continuous process (Demidova-Rice et al., 2012). Surgical wound dehiscence (SWD) has been defined as the separation of the margins of a closed surgical incision that has been made in skin, with or without exposure or protrusion of underlying tissue, organs, or implants. Separation may occur at single or multiple regions, or involve the full length of the incision, and may affect some or all tissue layers. A dehisced incision may, or may not, display clinical signs and symptoms of infection (Ousey,2018).

Despite improvements in contemporary preoperative care and suture materials, the rate of surgical wound disruption has not decreased in recent years (Sorensen et al., 2005). CIHI's Hospital Harm Results reports the number of preventable, unintended harm due to wound disruption as ranged from 3,581 events in fiscal 2014, to 5,435 events in fiscal 2019 (CIHI, 2020). This may be attributable to the increasing incidence of risk factors within the patient population outweighing the benefits of technical achievements (Sorensen et al., 2005).

The causes of SWD can be categorized as: technical issues with the closure of the incision (e.g., unravelling of suture knots); mechanical stress (e.g., coughing can cause breakage of the sutures or rupture of the healing incision after suture or clip removal/reabsorption); and disrupted healing (e.g., due to comorbidities or treatments that hamper healing, or as a result of a surgical site infection [SSI]) (Ousey, 2018). However, overall SSI is the strongest predictor of wound disruption (Moghadamyeghaneh et al., 2015). Abdominal wound disruption typically occurs at 10 +/- 6.5 days (median eight days) after surgery (Kenig et al., 2014). Hospital stay is significantly longer for patients with wound disruption, with a median of 36 days, compared to 16 days in a control group (van Ramshorst et al., 2010).

The prevention and management of surgical wound complications is a growing area of concern for patients, healthcare professionals, and administrators alike. In these times of rationalization of healthcare dollars, it is important to ensure that patients receive appropriate screening and care, beginning at the pre-operative assessment and continuing through to post-operative care and monitoring in the community. Best practice recommendations when combined with evidence-informed interventions should help clinicians develop the skills and tools needed to identify those at risk for complications and develop plans in collaboration with their patients to ensure a best practice approach (Harris, 2017).

Risk Factors

Factors that could increase the risk of postoperative wound dehiscence (AHRQ-PDI 14, 2016, *Kamel & Khaled, 2014):

  • Adult Patient related:

    • Anemia

    • Hypoproteinemia

    • Jaundice

    • Male gender

    • Overweight

    • Increasing age

    • Infection

    • Episiotomy*

    • Poor nutrition

    • Diabetes

    • Smoking

    • Malignancy

    • Chronic pulmonary disease

    • Presence of prior scar or radiation at the incision site

    • Non-compliance with postoperative instructions (such as early excessive exercise or lifting heavy objects)

    • Increased pressure within the abdomen due to fluid accumulation (ascites); inflamed bowel; severe coughing, straining, or vomiting

    • Long-term use of corticosteroid medications

  • Procedure related:

    • Emergency surgery

    • Types of surgery (clean vs. contaminated)

    • Surgical error

Factors that could increase the risk of postoperative wound dehiscence in the pediatric population (AHRQ PSI 11, 2016):

  • Wound infections

  • Age <1 year

  • Emergency surgery

  • Mechanical ventilation

  • Median or vertical incisions

  • Malnutrition

Importance to Patients and Families

Wound complications are a burden for patients, their families, and the healthcare system (Butcher & White, 2014). Poor healing can result in wound disruption which not only affects the patient's quality of life, but may also delay adjuvant therapies, increase post-operative discomfort, delay return to activity, and increase costs as a result of re-intervention, longer hospitalization and readmission. Pain, particularly during dressing change remains a significant factor. Apart from the distress caused, pain can lead to feelings of anxiety, anger, and depression (Woo, 2010). Accurate pain assessment and understanding of the type of pain, helps with decisions about when and how to give analgesia and what information needs to be shared with the multidisciplinary team (Taylor, 2010). Several risk factors can be mitigated before, during and after the operative period, suggesting that the risk of developing wound disruption in vulnerable patients also can be reduced.

Clinical and System Reviews, Incident Analyses

Given the broad range of potential causes of wound disruption, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.

  2. Use appropriate analytical methods to understand the contributing factors.

  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.

  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

Measures

Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures). In selecting your measures, consider the following:

You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.

Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter.

Whenever possible, use measures you are already collecting for other programs.

Try to include both process and outcome measures in your measurement scheme.

Discharge Abstract Database

Discharge Abstract Database (DAD) Codes included in this clinical category:

  • D23: Would Disruption

Concept: Disruption of surgical wound during the same hospital stay or an obstetric wound during the delivery episode of care.

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References

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