title: Postsurgery wound assessment and management practices: a chart audit.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: NHMRC Research Centre for Clinical Excellence in Nursing Interventions (NCREN), Centre for Healthcare Practice Innovation (HPI), Griffith Health Institute, Griffith University, Gold Coast, Qld, Australia.
authors.forename: Brigid M
authors.initials: BM
authors.lastname: Gillespie
authors.forename: Wendy
authors.initials: W
authors.lastname: Chaboyer
authors.forename: Evelyn
authors.initials: E
authors.lastname: Kang
authors.forename: Jayne
authors.initials: J
authors.lastname: Hewitt
authors.forename: Paul
authors.initials: P
authors.lastname: Nieuwenhoven
authors.forename: Nicola
authors.initials: N
authors.lastname: Morley
mesh_terms: D017558:Elective Surgical Procedures; D005260:Female; D006801:Humans; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D009736:Nursing Process; D011182:Postoperative Care / Q000451:nursing; D011184:Postoperative Period; D017410:Practice Guidelines as Topic; D020399:Practice Management / Q000592:standards*; D011793:Queensland / Q000453:epidemiology; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000451:nursing / Q000473:pathology / Q000517:prevention & control
keywords: clinical guideline; primary intention; quantitative approaches; surgical nursing; wound care