1133 - Surgical Incisional Outcomes - Speaking the Same Language: A Perioperative Imperative

Learning Outcome: By the end of this learning experience, participants will be able to recognize the limitations of current surgical incisional definitions in addressing the full range of postoperative wound complications, explain the clinical and systemic impacts of under-recognized and inconsistently documented outcomes such as dehiscence, infection, seroma, and hematoma (collectively termed DISH), and advocate for the development and adoption of more comprehensive, standardized definitions with severity grading to enhance surveillance accuracy, research quality, interprofessional communication, quality improvement efforts, patient safety, and resource optimization in modern surgical practice

Overview/Abstract: Surgical site infection (SSI) definitions, primarily those from the CDC/NHSN, have remained largely unchanged for over 25 years. The core classifications, superficial incisional, deep incisional, and organ/space infections, provide useful basic differentiation but fall short in capturing the full spectrum of postoperative incisional wound complications/outcomes encountered in surgical practice.
Equally critical incisional wound complications/outcomes, including Dehiscence, Infection, Seroma, and Hematoma (collectively - DISH), lack standardized definitions or scoring criteria. These four surgical wound outcomes are often poorly and inconsistently documented, resulting in significant under-reporting despite their substantial clinical impact, such as prolonged recovery times, increased hospital readmissions, and considerable economic burden.
There is an urgent need for more inclusive surgical site outcome definitions that explicitly encompass dehiscence, infection, seroma, and hematoma, while incorporating severity grading and aligning with real-world clinical practice. Adopting a unified, standardized terminology would dramatically improve surveillance accuracy, enhance research validity, strengthen quality audits and benchmarking, promote consistent perioperative nursing documentation and interprofessional communication. This will ultimately advance patient safety, resource optimization, and evidence-based perioperative care in modern surgical settings.

Description of Current State: the current state of surgical incisional classification primarily relies on the longstanding CDC/NHSN (National Healthcare Safety Network) definitions for surgical site infections (SSIs). These definitions, which focus on infectious complications, have seen only minor refinements in recent years (e.g., clarifications to criteria for deliberate opening/re-access of incisions, standalone organism identification for deep incisional SSIs, and handling of spontaneous dehiscence in deep cases), but the core structure has remained stable for over 25 years.
These categories apply to procedures meeting the NHSN operative procedure definition (incision through skin/mucosa in an operating room setting). Surveillance periods, risk stratification, and reporting tie to specific procedure codes (ICD-10-PCS/CPT mappings). Minor 2026 updates improved clarity around incision management (e.g., re-access, spontaneous dehiscence in deep criteria) but did not fundamentally expand or overhaul the framework.

Limitations and Broader Incisional Wound Complications:

While the CDC/NHSN system excels at standardizing infectious SSIs for surveillance, quality benchmarking, and public reporting, it does not fully capture the spectrum of non-infectious or related postoperative incisional complications commonly seen in practice. Complications like dehiscence (wound separation), seroma (fluid collection), and hematoma (blood collection)—often grouped informally as DISH (Dehiscence, Infection, Seroma, Hematoma), lack standardized, inclusive definitions or severity grading within official NHSN/CDC frameworks.

1. Dehiscence and spontaneous opening can contribute to SSI criteria if linked to infection signs/symptoms or positive cultures, but isolated dehiscence (without infection) is not classified as an SSI.
2. Seromas and hematomas are explicitly not considered SSIs unless they meet infection criteria (e.g., positive culture from aspirated fluid or signs of infection).
These gaps lead to under-reporting of clinically significant issues that prolong recovery, increase readmissions, and impose economic burdens.

Efforts to address this include emerging proposals (e.g., DISH classification system), which aims to provide a unified, severity-graded framework explicitly encompassing dehiscence, inflammation/infection, seroma, and hematoma. However, as of 2026, no major standardized, widely adopted expansion beyond traditional SSI categories exists in CDC/NHSN guidelines.

Incisional wound classification for surveillance and infection control remains anchored in the three-tier CDC/NHSN SSI system (superficial incisional, deep incisional, organ/space), with recent tweaks focused on precision rather than expansion. Calls for more comprehensive definitions - including non-infectious DISH elements, persist to better reflect real-world surgical outcomes, improve documentation, research, and patient care.

Description of Desired/Achievable State: The desired state for this lecture is a future where surgical site outcome definitions are comprehensive, standardized, and clinically relevant, explicitly encompassing the full spectrum of incisional wound complications, collectively Dehiscence, Inflammation/Infection, Seroma, Hematoma, beyond the limited and current CDC/NHSN SSI framework.

A unified terminology would includes severity grading, enabling consistent documentation, accurate surveillance, valid research, reliable quality benchmarking, and improved interprofessional communication.

This would dramatically reduce under-reporting of non-infectious complications (which can cause prolonged recovery, readmissions, and higher costs), enhance perioperative nursing practices, optimize resource use, advance evidence-based care, and ultimately elevate patient safety and outcomes in modern surgical settings.

Audience Engagement: Using PowerPoint as a visual aid to engage the audience, we will combine both lecture, visuals, polling questions, and a Q & A session

Additional Information:

Content/Topics: 1. Introduction
statistics on under-reported complications (readmissions, costs).
State the core problem: SSI definitions miss key outcomes.
Present overarching learning objective.

2. Current State: CDC/NHSN SSI Definitions
Brief history.
Core three classifications: Superficial incisional, Deep incisional, Organ/space (key criteria, periods).
Main limitations: Focus on infection only; excludes/poorly captures isolated dehiscence, seroma, hematoma.

3. The Gap: Dehiscence, Infection, Seroma, Hematoma.
Clinical & systemic impacts: Prolonged recovery, readmissions, economic burden, under-reporting from lack of standards, and
Why SSI system falls short (non-infectious events not classified as SSIs).

4. Proposed Solution: DISH Classification System
Emerging unified framework
Key features: Standardized terminology for all four
Benefits: Better surveillance, research, benchmarking, documentation, communication, patient safety, resource optimization.

5. Path to Desired State & Conclusion
Global adoption of inclusive, severity-graded definitions.
Impacts on the entire perioperative care team & evidence-based practice.
A Call to action: Advocate in your setting.
Quick recap of key messages.

6. Q&A

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