Nursing Center - Journal Issue

Abstract

The number of surgical patients receiving home care continues to grow as hospitals discharge patients sooner. Home health clinicians must gain knowledge of the wound healing stages and surgical wound classification to collect accurate data in the Outcome and Assessment Information Set-C (OASIS-C). This article provides the information clinicians need to accurately assess surgical wounds and implement best practices for improving surgical wounds in the home health patient.

Case Scenario: Mr. Smith

The home health nurse visits Mr. Smith to complete the start-of-care Outcome and Assessment Information Set-C (OASIS-C). OASIS-C is a data collection tool required by the Centers for Medicare and Medicaid Services (CMS) for all Medicare-certified home health agencies. The tool allows for measurement of patient outcomes over points in time, for example, start of care or resumption of care to discharge, and determines reimbursement for the Medicare patient.

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Mr. Smith spent 4 days in the hospital following surgery for repair of an abdominal aortic aneurysm. The nurse visits Mr. Smith to complete the home health start of care assessment. The nurse assesses an approximated incision located on the abdomen that is draining small amounts of serous fluid. The nurse observes intact staples with no areas of separation noted along the incision. The nurse notes a small scab with dried bloody drainage from a previous right femoral cardiac catheterization site. Does this patient have a surgical wound (M1340)? What is the status of the most problematic (observable) surgical wound (M1342)? This article explains the rules for determining if a surgical wound exists in OASIS-C. The clinician will obtain knowledge of the healing stages of surgical wounds to accurately answer OASIS-C questions related to surgical wounds.

OASIS-C Definitions-What Is a Surgical Wound?

The Centers for Medicare and Medicaid Services (CMS) provides guidance regarding what is and is not considered surgical wounds. Table 1 lists common wounds classified as either surgical or nonsurgical and can be used as a reference tool for clinicians who complete OASIS-C assessments.

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Table 1. Does This Patient Have a Surgical Wound?

The OASIS-C surgical wound item focuses on the integumentary system, which is composed of the skin, hair, nails, and sweat glands. OASIS-C excludes wounds created in the mucous membranes, cataract surgery of the eye, and surgeries via a vaginal approach (CMS, 2010a). Surgeries involving only the skin count as surgical wounds.

Considerations

Clinicians must consider the wound etiology, or the cause. Surgical interventions may be used to treat already existing wounds and these treatments do not change the classification of the wound as surgical for OASIS-C. The wound will remain the type of wound that originally existed. For example, a patient who falls and sustains a laceration requiring sutures does not have a surgical wound. The suturing did not cause the wound, but instead treats the wound. In this example, trauma caused the laceration. Thus, the patient does not have a surgical wound for OASIS-C purposes (CMS, 2007a). However, CMS (2007a) states a clinician should consider a traumatic wound requiring surgery to repair an internal organ or other internal damage as a surgical wound. For example, repair of a torn tendon or a ruptured internal organ does create a surgical wound.

A second example involves debridement. Debridement is a treatment to an existing wound and does not change the wound to being classified as surgical. A pressure ulcer that is debrided remains a pressure ulcer (CMS, 2010a). A diabetic ulcer that is debrided remains a diabetic ulcer. The surgical debridement of any wound does not change the wound's type. A simple incision and drainage of any wound is a treatment and does not create a surgical wound for OASIS-C reporting purposes. If, however, tissue or other structures are removed or a drain is placed, the resulting lesion would be considered surgical in OASIS-C (CMS, 2007b).

Another example of a surgical intervention is skin grafts. The skin graft treats an existing wound and so does not cause the wound. Therefore, CMS excludes skin grafts as surgical wounds in OASIS-C (CMS, 2010a). The donor site is considered a surgical wound until healed, but the receiving site is not.

CMS (2010a) states that a muscle flap creates a surgical wound. A muscle flap of a pressure ulcer changes that wound to a surgical wound and is no longer a pressure ulcer (CMS, 2010a).

Drain placement into a wound creates a surgical wound for OASIS-C. After drain removal, the wound remains surgical. An excisional biopsy, shave biopsy, or punch biopsy create surgical wounds in OASIS-C (CMS, 2007b).

Central line sites and venous access devices are considered surgical wounds in OASIS-C. Implanted venous access devices and arteriovenous shunts are surgical wounds as long as they are present in the body, even if/when they are no longer functioning (CMS, 2010a).

Needle puncture sites do not create surgical wounds. Examples include paracentesis and thoracentesis sites where a needle was used to withdraw fluid. This also includes cardiac catheterization sites and needle biopsy sites for other examples. If a cut-down procedure is performed, creating a larger wound than a simple needle puncture, a surgical wound remains (CMS, 2010d).

Ostomies

CMS (2010a) tells home health clinicians to exclude all ostomies from consideration as surgical wounds. This includes anything ending in ostomy such as colostomies, cystostomies, ileostomies, tracheostomies, nephrostomies, to name a few. Do not consider an ostomy that closes on its own as a surgical wound. However, an ostomy sutured closed qualifies as a surgical wound (CMS, 2010a). A chest tube site, which is a thoracostomy, is not considered a surgical wound in OASIS-C.

Surgical wounds are considered in OASIS-C until the site has been reepithelialized for approximately 30 days (CMS 2010a). After 30 days, the site would be documented as a scar and not included in "M1340 Does this patient have a surgical wound?" (CMS, 2010a).

In the opening case scenario, the nurse should recognize that Mr. Smith does have a surgical wound. The clinician must include the incision from the surgery as a surgical wound on OASIS-C assessments. The cardiac catheterization site is not considered a surgical wound because it was created by needle puncture only. The clinician must next answer M1342 Status of the Most Problematic (Observable) Surgical Wound. Mr. Smith has only one surgical wound, the incision, thus making it the most problematic. In situations where the patient has more than one area that is considered a surgical wound for OASIS-C purposes, the clinician must use his or her judgment in determining which wound is the most problematic. It may be the wound that is the largest, has the greatest complications, or is the most resistant to treatment (CMS, 2010a). To accurately answer the healing status, the clinician needs to understand the healing phases of wounds.

Four Healing Phases of Surgical Wounds

To complete the comprehensive assessment and answer the OASIS-C item for the healing status of the most problematic surgical wound, the clinician must understand the fundamentals of the wound healing process. Benbow (2007) describes the process of wound healing as life preserving. Wound healing prevents infection, promotes healing, and returns normal function to the body. The phases include hemostasis, inflammation, proliferation, and maturation (Baranoski & Ayello, 2008). The phases overlap each other during the healing process (Benbow, 2007).

(1) Hemostasis

Hemostasis occurs after wound injury as the first phase of wound healing. Wound bed bleeding causes the clotting cascade to begin. This phase stops bleeding and begins the process of repair (Benbow, 2007). Injured blood vessels release fibrinogen, and fibrinogen causes clot formation. This causes bleeding to cease and the body then begins to break down the clot through a mechanism known as fibrinolysis. The clot dissolves allowing additional cells to enter the wound bed, thus leading to the next phase of wound healing, which is inflammation (Baranoski & Ayello, 2008).

(2) Inflammation

During the inflammatory phase, blood vessels become more permeable and dilate. Growth factors released by platelets cause this to occur. White blood cells enter the wound and work to destroy bacteria and clean debris (Benbow, 2007). The patient may exhibit redness, swelling, warmth, and discomfort around the wound bed during this phase of healing. Patients need reassurance that these symptoms normally occur at this stage and do not likely indicate infection. The inflammatory phase begins within hours of wound creation and can last several days. The proliferation phase follows the inflammatory phase (Benbow, 2007).

(3) Proliferation

The proliferation phase begins approximately 3 to 6 days after wound occurrence and can last several weeks in an open wound (Baranoski & Ayello, 2008; Benbow, 2007). Granulation may occur during this phase. Granulation tissue appears as small, berry-like growths in a wound. An approximated incision does not fill with granulation tissue because no tissue loss occurs.

During the proliferation phase, the risk of dehiscence increases because of the fragility of the new tissue. The wound develops new blood supply that provides essential nutrients to the healing wound (Baranoski & Ayello, 2008).

Epithelialization occurs during the proliferation phase. Cells migrate across the wound to cover the surface with new skin (Benbow, 2007). This process begins a few hours after injury. Epithelial cells travel across the skin from healthy wound edges. Closed wound edges will not allow for cell migration. Closed wound edges include rolled, calloused, or hyperkeratonic edges (Peirce et al., 2009). The edges may appear hard and thickened. The clinician may also note discoloration. Healthy wound edges remain open or flat, allowing for easy cell migration. In addition, a warm, moist wound bed aids in cell migration. Eschar development interferes with and slows wound healing. Debridement of necrotic tissue may be necessary (Benbow, 2005).

(4) Maturation

Beginning as early as 7 days after injury, the final healing phase occurs (Baranoski & Ayello, 2008). Epithelial cell migration completes and wound contraction begins. The new tissue strengthens during this phase as the tissue matures. The maturation phase lasts up to 1 year. Wound strength will never regain to the point that existed prior to wound injury. Baranoski & Ayello (2008) state that wounds regain only 70% to 80% of the original tissue strength that existed prior to injury.

The Classification of Surgical Wounds

Primary and Secondary Intention

The wound healing phases differ with the classification of wound healing. Surgical wounds heal by either primary intention or secondary intention. Both healing classifications progress through the same healing phases, but at different rates. This section of the article discusses the differences in these types of healing.

Primary Intention

Primary intention healing occurs when all tissues are surgically closed following the operation. Approximated incision, meaning that the edges are brought together without areas of separation, heal by primary intention. Figure 1 depicts a surgical wound healing by primary intention. Surgically closed wounds sustain less tissue loss. This minimizes the need for new tissue formation (Vuolo, 2006). Wounds healing by primary intention typically heal faster and leave smaller scars than open surgical wounds. The resulting scars appear flush with the skin as opposed to being depressed (Vuolo, 2006). No granulation tissue will form because there is no vacant space needing to be filled in (CMS, 2010a).

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Figure 1. Abdominal Surgical Wound Healing by Primary Intention.

The inflammatory phase of healing begins during the first 24 hours. Epithelial cell migration starts. Normally wound closure occurs in 2 to 3 days in approximated incisions (Benbow, 2007). Benbow (2005) states the surface edges of an incision seal together 24 to 48 hours after wounding through epithelialization. Drainage ceases when closure occurs.

The proliferation phase shortens in wounds healing by primary intention because new tissue does not need to fill the wound bed. The granulation process will not occur (CMS, 2010b). No gaps or dead space exists in wounds brought together surgically. These wounds typically heal faster and with fewer complications than wounds healing by secondary intention (Vuolo, 2006).

Secondary Intention

Open surgical wounds heal by secondary intention. Secondary intention healing occurs when the wound edges are open, thus requiring granulation tissue to form and fill in the open space. This includes wounds left open intentionally and approximated surgical wounds that dehisce or separate (Vuolo, 2006). Figure 2 depicts a wound healing by secondary intention. Granulation tissue from the base of the wound must fill the wound bed (Benbow, 2007). Epithelialization cannot occur until the granulation tissue reaches the level of the surrounding skin. Again, the phases of healing remain the same. Wounds healing by secondary intention take longer to heal. The proliferation phase takes longer due to the need for additional granulation tissue development.

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Figure 2. Abdominal Surgical Wound Healing by Secondary Intention.

Surgical closure of an infected wound greatly increases the risk of dehiscence. For this reason, physicians often leave dirty or infected wounds open to heal by secondary intention (Vuolo, 2006).

Approximated incisions begin healing through primary intention; any subsequent incisional dehiscence or separation results in secondary intention healing in that area.

M1342 Status of Most Problematic Surgical Wound

With knowledge of the phases of wound healing and primary versus secondary intention, the clinician can answer M1342 Status of Most Problematic (Observable) Surgical Wound. CMS (2010a) provides four possible choices when answering this M item.

* Newly epithelialized

* Fully granulating

* Early/partial granulation

* Not healing

The Wound, Ostomy, and Continence Nurses Society Guidance on OASIS-C items provides definitions noted in Table 2 (Peirce et al., 2009). Recent guidance from CMS (2010a) reiterates that wounds healing by primary intention do not granulate. The close proximity of wound edges leaves no areas for granulation to occur. Therefore, only "Newly epithelialized" and "Not healing" choices apply to M1342 for approximated incisions.

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Table 2. WOCN Healing Status Definitions for Completing M1342

The clinician must next complete a careful assessment to determine if complete approximation exists along the entire incision. Any separation along the incision creates areas healing by secondary intention. Wounds healing by secondary intention require granulation tissue. All four choices apply to M1342 for open surgical wounds (CMS, 2010c).

Mr. Smith

Consider again the scenario of the patient Mr. Smith. The completely approximated incision falls into the primary intention-healing category. When answering M1342 Status of the Most Problematic Surgical Wound, the clinician should only consider two possible choices: "Newly epithelialized" and "Not healing." Typical incisions seal through epithelialization in 24 to 48 hours. However, the presence of continued drainage indicates that Mr. Smith's incision does not demonstrate complete epithelialization. The clinician should select "Not healing" as the correct choice. "Newly epithelialized" does not apply here because complete epithelialization did not yet occur. The clinican should recognize that Mr. Smith's wound is at a greater risk for complications due to the drainage persisting beyond 24 to 48 hours.

Consider a change to this case scenario. Mr. Smith goes to a rehabilitation hospital following his hospital stay. The home care nurse assesses Mr. Smith 14 days following his surgery. The incision appears approximated with one open area at the incision's distal portion. The area of separation measures 1 cm long .3 cm wide and drains serous fluid. The nurse notes granulation tissue partially filling the open area, but not up to the level of the surrounding skin. No necrotic tissue presents in the wound and no signs or symptoms of infection exist. The nurse observes epithelialization over the remainder of the incision. Mr. Smith's wound will now heal by secondary intention, due to the separated area along the incision. All four choices to M1342 apply. The clinician should record "Early/partial granulation" as the correct response to M1342 based on guidance from the Wound, Ostomy, and Continence Nurses Society (Peirce et al., 2009). Refer to the flow chart in Figure 3. Clinicians can use this tool to aid in the decision-making process for selecting the correct response for the healing status item. Accurate responses to this area are very important. This item is used to reflect the percentage of patients whose surgical wounds improve during a home health episode of care and this has implications for an agency's outcome data.

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Figure 3. Healing Status of Most Problematic Surgical Wound. From Home Nursing Agency. Definitions are those of Wound Ostomy Nurses Society "Guidance on OASIS-C Integumentary Items" by B. Peirce, D. Mackey, L. McNichol, 2009.

Staples and Sutures

The presence of staples or sutures should not affect the healing status of the wound for OASIS-C (CMS, 2011). Figure 1 shows an abdominal incision 5 days after surgery. The incision is completely approximated with no drainage, no separation, and no signs/symptoms of infection. Figure 4 depicts the same incision 10 days postoperatively, and Figure 5 is at 14 days postoperative. In all three of these pictures, the wound's healing status is "Newly epithelialized." No complications exist in this wound. Recent instructions from CMS inform home care clinicians that any opening in the skin caused by staple or suture removal adjacent to the incision line is not to be considered as part of the surgical wound (CMS, 2011).

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Figure 4. Abdominal Surgical Wound Healing by Primary Intention.

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Figure 5. Abdominal Surgical Wound Healing by Primary Intention.

Best Practice for Improving Surgical Wounds

Assess for Complications

The first step in improving surgical wounds in home health patients involves an accurate wound assessment. This accurate assessment includes correctly determining the healing status for OASIS-C, but also assessing the wound to determine if complications of the wound exist. The clinician should assess for complications including dehiscence, infection, redness, drainage, and delayed wound healing.

Dehiscence. Wound dehiscence usually occurs around the seventh postoperative day. Drainage from an incision healing by primary intention should cease within 48 hours. Drainage lasting beyond 48 hours indicates a potential for dehiscence (Hunter, Thompson, Langemo, Hanson, & Anderson, 2007). Additional warning signs for dehiscence include signs and symptoms of infection. Doughty (2005) states dehiscence occurs more frequently in the presence of infection. Mechanical stress on the wound bed from heavy lifting, coughing, sneezing, and straining also increases the chance of dehiscence (Vuolo, 2006).

Infection. Kaye, Anderson, Sloane, Chen, Choi, Link, Sexton, and Schmader (2009) found that surgical site infection in the elderly leads to increased mortality, longer hospitalization, and higher healthcare costs. Carefully assess wounds for signs of infection. Drainage beyond 48 hours indicates an increased risk for infection. Without normal wound closure, risk of bacterial invasion increases (Hampton, 2007). The clinician should make preventing infection, promoting healing, and closing the wound the priorities.

Dressing residue, dried blood, or drainage along closed surgical wounds provides potential sources of infection. Avoid trauma by cleansing around the wound gently with saline-moistened gauze. In open surgical wounds, avoid wiping the wound bed with gauze. This can cause a new inflammatory response if bleeding occurs and lead to a delay in wound healing (Vuolo, 2006).

Systemic factors. Multiple factors can cause delayed wound healing. Patients with circulatory disorders and diabetes may exhibit delayed wound healing. Diseased blood vessels lack the ability to adequately provide the necessary nutrients for wound healing (Benbow, 2007). Malnutrition and inadequate protein intake also delay wound healing.

Patient Education

Clinicians should instruct patients and caregivers on proper surgical wound care. Education should focus on preventing dehiscence, preventing infection, and promoting wound healing.

Prevent Dehiscence. Educate patients to splint incisions and wear support garments if appropriate. Instruct patients on proper body movements to prevent undue strain to wound areas (Vuolo, 2006). Teach patients and caregivers to monitor for signs of complications such as continued drainage, redness, warmth, or swelling along the incision, and increased incisional pain (Hunter et al., 2007). Observe for signs and symptoms of infection and begin treatment early. Educate patients and caregivers on when to notify the physician to report changes or symptoms.

Prevent Infection. Educate patients about the signs and symptoms of infection, good hand washing/hygiene techniques, and appropriate wound care. Teach patients to inspect wound regularly. Recognizing symptoms of infection early leads to improved success with wound management (Vuolo, 2006). Educate patients and caregivers on proper wound cleansing, use of gloves, and environmental cleanliness. Teach ill caregivers to wear a mask when performing wound care.

Promote Healing. Instruct patients with diabetes to monitor blood glucose levels regularly to maintain tight glucose control and promote wound healing (Benbow, 2007). Educate all patients on increasing their protein intake or consider adding a protein supplement. Foods high in protein include meats, poultry, fish, legumes, eggs, nuts, dairy products, and grains (Center for Disease Control and Prevention, 2009).

The Implications for OASIS-C

CMS publically reports the percentage of home health patients who achieve an improvement in surgical wound status. The focus on improving surgical wound status comes from a doubling of healthcare dollars Medicare spent on hospital stays for surgical wound complications (Schwien & Lang, 2008). The percentage of hospital discharges to home health for patients with infected wounds continues to rise. The home care industry provides a cost-effective and efficient resource for healing wounds and preventing complications (Schwien & Lang, 2008). Clinicians who possess the knowledge of how to accurately assess, treat, and educate patients with surgical wounds should show higher rates of improvement.

Conclusion

Clinicians caring for patients with surgical wounds must understand the categories, classification, and wound healing phases. Accurate data collection begins with determining if the patient has a wound that meets CMS criteria as a surgical wound. Clinicians then need to determine the healing status of surgical wounds in OASIS-C. Only responses of "Newly epithelialized" or "Not healing" apply in M1342 for wounds healing by primary intention. Granulation occurs in wounds healing by secondary intention. Clinicians must select the appropriate response from "Newly epithelialized," "Fully granulating," "Early/partial granulation," and" Not healing" for this type of surgical wound healing. Surgical wounds that are completely epithelialized for more than 30 days are no longer considered in the OASIS data items. Clinicians should focus on recording accurate responses to M1342 Healing Status of the Most Problematic Surgical Wound, assessing for complications and educating patients as important steps for improving outcomes.

Mr. Smith received education on signs and symptoms of infection, complications of the wound, methods to prevent dehiscence, and foods to include to increase protein intake from the visiting nurse. The drainage stopped and his incision healed without complication. Epithelialization of the incision occurred by the third home health visit. The healing status of Mr. Smith's surgical wound was "Newly epithelialized" at discharge, showing an improvement in the status of his surgical wound for OASIS-C. Thanks to the accurate wound assessment and teaching skills of the visiting nurse, Mr. Smith made a full recovery.