Quality Improvement Project: Wound Dehiscence

Michael Phelps
Bon Secours Memorial College of Nursing
November 16, 2014
I Pledge

Quality Improvement Project: Wound Dehiscence

Wound dehiscence is defined as parting of the layers of a surgical wound. (Duffek, 2014)
Wound dehiscence is considered to be a serious complication and requires medical treatment.
The Agency for Healthcare Research and Quality estimated as of 2011 that 1.83 per 1000 people
will develop a postoperative wound dehiscence. (Agency for Healthcare Research and Quality,
2014).
There are several factors that can cause a wound dehiscence: infection, pressure on the
sutures, tight sutures, secondary injury to the wound, weak tissue, inadequate suture technique,
long-term steroid use, vitamin C deficiency, and comorbidities. Certain comorbidities,
especially diabetes and smoking, increase the potential for wound dehiscence. (Doughty, 2004).
Obesity, advanced age, poor nutrition, anemia, immune problems, cancer, and kidney problems
are other comorbidities that can lead to wound dehiscence. (Duffek, 2014).
In order to decrease the number for wound dehiscence each year certain guidelines and
strategies should be met. Granted, we cannot tell people who smoke that they cannot have
surgery. However, we can recommend no smoking for at least 30 days before their surgery.
(Doughty, 2004). With patients with diabetes, an HgbA1C should be performed to see how well
controlled the patients diabetes is maintain. (Doughty, 2004). The level should be no more than
7%, any greater and there is an increased risk of postoperative complications. (Schurr & Faucher,
2011). Unless the surgery is urgent or emergent, the patient should have their diabetes well
under controlled. Patients should be encouraged to protein-rich foods (meats, fish, milk, cheeses,
and beans). Some surgeons will not operative on obese patients until they lose a certain amount
of weight or reach a certain height/weight ratio. (Schurr & Faucher, 2011) I think, in order to
decrease the risk of a wound dehiscence, a certain BMI or height/ weight ratio needs to be met.

Quality Improvement Project: Wound Dehiscence

It is also recommended that steroid use be tapered for long time user, and anti-inflammatory
drugs be discontinued prior to surgery. (Doughty, 2004).
During the surgery, while in the operating room, the patient should be kept warm for
prevention of vasoconstriction. (Doughty, 2004) Warm IV fluids, warm forced air, heated
mattress, and blankets can be used to maintain warmth. For diabetic patients in the operating
room, periodic blood glucose levels should be checked. (Doughty, 2004). Retention sutures can
be used to reduce the incidence of wound dehiscence; however, retention sutures will get rid of
it. (Hahler, 2006). Incisional supports (abdominal binders, surgical bras, etc.) should be
encouraged for malnourished, chronic coughers, chronic steroid users, obese or large breasted
individuals. (Doughty, 2004). The use of a continuous suturing technique is more effective than
an interrupted suture technique. Also, the use of a suture has shown to be more effective in
reducing the development of hernias. (Schurr & Faucher, 2011). With the use of absorbable
monofilament suture that is 4 times longer than the wound, the chance of a wound dehiscence
decreases. (Schurr & Faucher, 2011)
After the surgical procedure, the patient should be kept warm in order to facilitate
vasodilation. Pain management should occur immediately after surgical dressing are applied and
follow the patient into post-anesthesia care and onto the floor or home. (Doughty, 2004). Upon
the floor, 24 to 48hrs, the nurse should as the patient how the wound feels and visual inspection
should take place every 24 hours. While paying closure attention on day 4 and 5, take note if the
patient states a pulling or ripping sensation or something has given way and there is
evidence of serosanguinous drainage it should be documented and the surgeon notified. (Hahler,
2006).

Quality Improvement Project: Wound Dehiscence

Once dehiscence has to diagnosed and verified. Eliminating abdominal pressure should
be implemented by placing the bed in trendelenburg position, at most 20 degrees. (Hahler, 2006)
The patient should be encouraged not to cough, and can bend their knees. (Hahler, 2006). A
culture of the serosanguinous drainage should be performed and antibiotics administered. (Schurr
& Faucher, 2011). Serosanguinous wound drainage around day 4 or 5 is a sign that failure of the
fascia has taken place. (Schurr & Faucher, 2011).
A Quality Improvement Project for wound dehiscence should be implemented. First,
criteria should be met before surgical even becomes an option, unless the surgery is lifethreatening and/or emergent. The patient should either be a non-smoker or cease tobacco use for
at least 30 days before surgery (Doughty, 2004). The patient should be a non-diabetic or have an
HgbA1C of no greater than 7% before surgery is even planned. (Schurr & Faucher, 2011). If the
patient is not less than 7%, the patient needs to be educated on diabetic control and retested after
3 months. Protein deficient patients should be encouraged to increase their protein intake. All
anti-inflammatory drugs should be discontinued prior to surgery, unless the medication is
important for bodily function. (Doughty, 2004). And, obese patients should attempt or currently
be in the process of decreasing their weight to a manageable BMI or height/weight ratio that the
surgeon has specified. (Schurr & Faucher, 2011). These criteria should be met only on elective
non-urgent surgical procedures. Once surgery has been approved, supplements for anemic
patients should be administered. Once in surgery, patients should be kept warm. Diabetic
patients should have their blood glucose checked before, during, and after the procedure. (Schurr
& Faucher, 2011). For those emergent procedures on obese or at risk dehiscence patients,
retention sutures should be considered or at least an option. (Hahler, 2006). Abdominal binders
and surgical bras should be used on chronic coughers, heavy steroid users, and obese and/or

Quality Improvement Project: Wound Dehiscence

large breasted individuals. (Doughty, 2004). An absorbable monofilament suture 4 times longer
than the wound should be used. (Schurr & Faucher, 2011). Outside of surgery, the patient should
be kept under pain management and encourage to suppress excessive coughing. (Doughty,
2004). The patient should be kept warm. Once the patient has arrived on the floor, the wound
should be assessed after 24 to48 hours. By day 4 or 5 of post-surgery, the wound should be
assessed for any serosanguinous drainage. If serosanguinous drainage and patients verbalize that
something is wrong with the wound, the surgeon should be notified. A protocol should take
place after the diagnoses and verification of a dehiscence has occurred. The floor nurse should
take the culture sample and administer the antibiotics that the surgeon has placed in there
dehiscence protocol orders. Also, the patient should be either prepared for surgery or have a
vacuum-assisted closure device attached.
As a result of this purposed Quality Improvement Project, nurses and surgeons in the
office will have the increased paper/office work. They will need to make sure an HgbA1C is
performed on their diabetic patients. And, if the patient is not below the 7%, the patient will
need to wait until the HgbA1C is adequate enough for surgery. Weight reduction will need to be
encouraged. Steroid users will need to be tapered on medication use. Tobacco users will need to
be encouraged to cease use. Intraoperative nurses will need to check blood glucose before,
during, and after surgery. Scrub nurses and circulators will need to make sure the appropriate
suture is being used. Abdominal binders and bras are used appropriately. Floor nurses will need
to manage pain more effectively. They will need to recognize and realize at risk patients for
dehiscence. The floor nurses will need to understand the wound dehiscence protocol for early
detection and correction of a wound dehiscence. As well as, take culture samples and apply
treatment specified by the surgeons dehiscence protocol. Unfortunately, this project would

Quality Improvement Project: Wound Dehiscence

decrease the number of cases performed each month. However, hospital stay will be decreased
due to reduction of potential dehiscence of a patient, and early detection of dehiscence by
medical personnel. The population at greatest discouragement will be diabetic patient with
uncontrolled glycemic index.

Quality Improvement Project: Wound Dehiscence

Postoperative Wound Dehiscence

Postoperative Wound
Dehiscence (2011)
Postoperative Wound
Dehiscence (2012)
Postoperative Wound
Dehiscence (2013)
Postoperative Wound
Dehiscence (2014)

January

February

95%

79%

93%

August

September

October

November

December

80% 90% 86% 72% 79%

86%

90%

87%

81%

82%

80%

79% 86% 90% 74% 90%

88%

92%

89%

82%

84%

97%

81%

78% 87% 86% 78% 86%

84%

90%

90%

80%

85%

96%

83%

82% 90% 97% 80% 91%

87%

93%

91%

85%

87%

Below 75%
At or Above
75%
At or Above
90%

March

April

May

June

July

Quality Improvement Project: Wound Dehiscence

References
Agency for Healthcare Research and Quality. (2014). Fact Sheet on Patient Safety Indicators.
Retrieved from Agency for Healthcare Research and Quality:
http://www.ahrq.gov/professionals/systems/hospital/qitoolkit/a1b_psifactsheet.pdf
Doughty, D. B. (2004, June). Preventing and Managing Surgical Wound Dehiscence. Home
Healthcare Nurse, pp. 364-367.
Duffek, C. (2014, August). Wound Dehiscence. Retrieved from NYU Langone Medical Center:
http://www.med.nyu.edu/content?ChunkIID=99918
Hahler, B. (2006). Surgical Wound Dehiscence. Medsurg Nursing, 296-300.
Ko, Y. S., & Jun, S. W. (2014). Vacuum-assisted close versus conventional treatment for
postlaparotomy wound dehiscence. Annals of Surgical Treatment and Research, 260-264.
Schurr, M., & Faucher, L. (2011). Postoperative and Adjunctive Wound Care. Scientific
American Surgery, 1-13.