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.