Postoperative Incision Care Auditing Tool
Purpose:
It is Sunnybrook’s intent to verify that the care of surgical incisions postoperatively is in accordance with Sunnybrook
policies in an effort to reduce the incidence of surgical site infections (SSIs).
Definitions:
Primary intention = wound closure immediately following the injury and prior to the formation of granulation tissue
Saturated operative dressing = where the drainage from the post-surgical wound soaks through all dressings applied in the
operating room (OR), before time of ordered dressing reduction. (Usually Post-operative Day 0 or Day 1).
Open and draining incision = A surgical wound where the margins of the incision have not sealed completely and the wound is
draining serous, serosanginous or purulent drainage.
Clean and Intact incision = A surgical wound where the margins of the incision have sealed and no or minimal drainage is present.
(Usually occurs after 24-48h post-operatively).
Abbreviations: HH = hand hygiene (either alcohol-based hand rub OR soap & water), PPE= Personal Protective Equipment, HCW =
Health care worker, MOG = glove use without hand hygiene
Department/Area to be audited:
Type of wound closure
_______________________________________
□Primary intention □Secondary intention □Vacuum Assisted Closure (VAC)
□<24 hrs □Post-op Day 1 □Post-op Day 2 □>48 hrs
How old is the wound?
Protocol
A. Dressing Change using minimal
barrier aseptic technique
B. Dressing change using maximal barrier aseptic
technique
Indication
□ Clean Intact Incision
□ Initial Post-op Dressing Change
□ Saturated Operative Dressing
□ Open & Draining incisions
A. Minimal
B. Maximal
Equipment
(check if present)
□ Clean gloves
□ 50ml sterile
□ Clean gloves □ Waste bag for
normal saline
□ Sterile gloves
□ Sterile gloves used dressings
irrigation solution
□ 50ml sterile
□ Waste bag for used □Dressing supplies □ Mask
normal saline
dressings
as needed
irrigation solution
□Gown
□ Dressing Tray
□ Sterile dressing
supplies as needed
(if needed)
Preparation
Was the patient offered analgesia?
Has privacy been ensured?
Has all equipment been collected and
placed on a clean surface?
Has HH been performed before opening
dressing packages?
Precautions
Is appropriate PPE
being worn?
□YES
□YES
□YES
□YES
□NO
□NO
□NO
□NO
A. Minimal
□Yes, with reminder
B. Maximal
□YES
□NO
□YES
(clean gloves only)
Was PPE applied in
proper sequence?
N/A
(HH, mask, gown, gloves)
Was the sterile field maintained throughout
the procedure?
□YES
□YES
□NO
(mask, gown needed if soiling of clothes is likely, and clean gloves)
□NO
□NO
Checklist for Postoperative Incision Care Audit
1
Cleaning
Is the HCW using sterile gloves?
□YES
□YES
□YES
□NO
□NO
□NO
□Yes, with reminder
□NO
□NO
□NO
□NO
□Yes, with reminder
Was clean tape used to secure the new
dressing? (i.e. from the trolley, not a pocket)
□YES
□YES
□YES
□YES
Have the wound & surgical dressing been
kept out of contact with tap water?
□YES
□NO
□YES
□NO
□Yes, with reminder
Was PPE removed & disposed of in the
proper sequence: gloves & gown (HH) then
mask (HH)?
Hand Hygiene
□YES
□NO
□Yes, with reminder
Was HH performed:
_____ Before donning clean gloves/
removing soiled dressing
_____ After removing soiled dressing &
gloves/before donning sterile gloves
_____ After applying new dressing &
removing sterile gloves
B. Maximal
_____ After any direct contact with the
surgical site
Is the cleansing solution being used normal
saline (as per policy)? If no, state other.
Is the wound being cleaned from the
incision line outwards (clean to dirty) in one
direction only?
Is each cleaning pad used only once?
Is a culture swab being taken?
If yes, has the area first been cleaned of any
frank pus?
Disposal
Were dressings disposed of properly?
(minimally contaminated dressings in the regular
garbage; heavily contaminated [i.e. with blood]
dressings in yellow bags)
Y = yes
N = no
WR = yes, with reminder
MOG = glove change without HH
Documentation
Has the wound been
assessed, and the
following findings
documented:
A. Minimal
□ Condition of the wound
□ Pain & comfort of patient
Other:
□Yes, with reminder
□Yes, with reminder
□Yes, with reminder
□ N/A
□ N/A
□ N/A
□ Condition of the wound
□ Pain & comfort of patient
□ Drainage – amount, type (serous, sanguineous, etc.), colour,
odour
If the patient is being discharged, have they
been given wound care instructions? If yes,
what type?
Level of Knowledge
Has the staff member ever received
education/ training surrounding wound
care?
Is the staff member aware of SB’s policy
for post-op incision care?
□YES
□NO
□ N/A (not being discharged)
(Check all that apply)
□Verbal □ Hand-written □ Pamphlet
□YES
□NO
□YES
□NO
Source: Postoperative Incision Care (Policy CLS-0032); Last revised August 2008.Available at: http://sunnynet.ca//Default.aspx?cid=100798&lang
Auditor Signature:
Date:
____________________
(MM/DD/YYYY) ______ /
Print name: ________________________
Dept: __________________
_______ /_________
Position: _________________
Checklist for Postoperative Incision Care Audit
2