Postsurgery wound assessment and management practices: a chart audit
Article first published online: 8 MAR 2014
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing
Volume 23, Issue 21-22, pages 3250–3261, November 2014
How to Cite
Gillespie, B. M., Chaboyer, W., Kang, E., Hewitt, J., Nieuwenhoven, P. and Morley, N. (2014), Postsurgery wound assessment and management practices: a chart audit. Journal of Clinical Nursing, 23: 3250–3261. doi: 10.1111/jocn.12574
- Issue published online: 13 OCT 2014
- Article first published online: 8 MAR 2014
- Manuscript Accepted: 25 JAN 2014
- Queensland Government Department of Employment
- Economic Development & Innovation Smart Futures Research
- Australian College of Nursing
- clinical guideline;
- primary intention;
- quantitative approaches;
- surgical nursing;
- wound care
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.
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.
A retrospective clinical chart audit
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.
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.
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.