Postsurgery wound assessment and management practices: a chart audit.

AIMS AND OBJECTIVES To examine wound assessment and management in patients following surgery and to compare these practices with current evidence-based guidelines for the prevention of surgical site infection across one healthcare services district in Queensland, Australia. BACKGROUND Despite innovations in surgical techniques, technological advances and environmental improvements in the operating room, and the use of prophylactic antibiotics, surgical site infections remain a major source of morbidity and mortality in patients following surgery. DESIGN A retrospective clinical chart audit METHODS A random sample of 200 medical records of patients who had undergone surgery was undertaken over a two-year period (2010-2012). An audit tool was developed to collect the data on wound assessment and practice. The study was undertaken across one healthcare services district in Australia. RESULTS Of the 200 records that were randomly identified, 152 (76%) met the inclusion criteria. The excluded records were either miscoded or did not involve a surgical incision. Of the 152 records included, 87 (57·2%) procedures were classified as 'clean' and 106 (69·7%) were elective. Wound assessments were fully documented in 63/152 (41·4%) of cases, and 59/152 (38·8%) charts had assessments documented on a change of patient condition. Of the 15/152 (9·9%) patients with charted postoperative wound complications, 4/15 (26·6%) developed clinical signs of wound infection, which were diagnosed on days 3 to 5. CONCLUSIONS The timing, content and accuracy of wound assessment documentation are variable. Standardising documentation will increase consistency and clarity and contribute to multidisciplinary communication. RELEVANCE TO CLINICAL PRACTICE These results suggest that postoperative wound care practices are not consistent with evidence-based guidelines. Consequently, it is important to involve clinicians in identifying possible challenges within the clinical environment that may curtail guideline use.