CONCEPTS
wounds, outpatient
Oatpatient WoundPreparation and Care" A National Survey From Northeastern Ohio Universities College of Medicine, Akron, Ohio;* and Methodist Hospital of Indiana, Inc, and the Indiana University School of Medicine, Indianapolis. t Received for publication November 7, 1991. Revision received February 27, 1992. Accepted for publication April 3, 1992.
John M Howell, MD, FP,CEP* Carey D Chisholm,MD, FACEP*
Study objectives: To sample the practice styles of emergency physicians caring for acute traumatic wounds.
Design: Written survey. US emergency departments obtained from the American College of Emergency Physicians mailing list. Setting:
Subjects: Randomly selected ACEP members. M a i n results: One hundred fifty-one of 285 (53%) survey mailings were returned. Eighty-six percent of respondents were primarily clinicians, and the majority (61.6%) worked in EDs with annual patient visits between 21,000 and 50,000. The majority of respondents (64.2%) were certified by the American Board of Emergency Medicine. Nineteen percent managed wounds based on provider preference despite the existence of written wound management protocols. We identified a variety of practices that are contrary to current literature and textbook recommendations. Fifty-eight (38%) soaked wounds, whereas 21% used either 10% povidone iodine or hydrogen peroxide to cleanse wounds. One hundred one (67%) scrubbed the entire wound surface using, among other methods, cotton gauze (59%) or a coarse, bristle-laden sponge (38%). Forty (27%) irrigated wounds using techniques that have not been proven to deliver the 5 to 8 psi necessary for adequate tissue cleansing. Delayed primary closure, a treatment option for lacerations at increased risk for infection, was infrequently or never practiced by 76% of respondents. All respondents administered IV antimicrobials at least occasionally for simple outpatient lacerations. Conclusion: Methods of preparing, treating, and following outpatient wounds vary among emergency physicians, and these results support the idea that no de factostandard of care exists for this clinical problem. Outpatient wound care techniques routinely practiced {ie, soaking, scrubbing, use of full-strength hydrogen peroxide or fullstrength povidone iodine) may be harmful based on limited animal and human research, whereas other proven techniques (ie, delayed primary closure) are infrequently practiced by many emergency physicians. [Howell JM, Chisholm CD: Outpatient wound preparation and care: A national survey. Ann EmergMedAugust1992;21:976:981 .]
102/976
ANNALS OF EMERGENCYMEDICINE 21:8 AUGUST1992
WOUND CARE
Howell& Chisholm
INTRODUCTION
Approximately ten million patients with traumatic wounds are treated annually in US emergency departments.1 Wound infections occur in fewer than 10% of emergency patients, but when they occur they have a deleterious effect on healing, tissue strength, and cosmesis. 2 P r o p e r wound p r e p a r a tion and closure should diminish suppurative complications. However, a standardized a p p r o a c h to the care of outpatient traumatic wounds has yet to be established, in p a r t because of a paucity of statistically powerful clinical studies. This is compounded because few medical schools devote formal and standardized curricula to wound healing and management: Thus, we believe most practitioners in the United States use personal experience and preference when caring for outpatient wounds and that a de f a c t o s t a n d a r d of care does not exist. Using a survey format, we obtained information regarding tetanus prophylaxis and the p r e p a r a t i o n , cleansing, closure, dressing, follow-up, and antimicrobial and analgesic t h e r a p y of outpatient traumatic wounds treated by emergency physicians. The purpose of gathering this information was to identify variations in methods of treatment to serve as targets for research. MATERIALS
AND
METHODS
We mailed the survey in March 1991; the authors wrote the survey in consultation with a statistician. Before mailing, the survey was administered to four American B o a r d of Emergency Medicine-certified attending and four resident level emergency physicians. After this initial validation process, minor changes were made in the wording of the survey to ensure clarity and accuracy. Several closed questions asked respondents to identify practice frequencies in terms of percentages. F o r example, the term frequently was defined as more than 75% frequency; sometimes, 26% to 74%; infrequently, less than 25%; rarely, less than 5%. The names and addresses of 285 emergency physicians were generated randomly from the membership list of the American College of Emergency Physicians. A cover letter from the president of ACEP encouraged participation. The denominator used to calculate the percentage of positive respondents was the number of respondents to each question and not the total number of surveys returned. F o r many questions regarding methods of treatment, respondents were instructed to choose as many answers as were applicable. For example, many providers chose several different soaking or irrigation solutions, which they apparently use at different times. Under a limited n u m b e r of questions, respondents were asked to write " o t h e r " answers where appropriate. Bhnded data entry was performed and descriptive statistics were generated for each response.
AUGUST1992
21:8
ANNALS OF EMERGENCY MEDICINE
RESULTS We received 151 responses to 285 survey mailings (53%). Seven of 39 questions (18%) were not answered with varying frequencies. The mean number of nonrespondents to each unanswered question was 9.85 + 10.44, with a range of one to 29. The questions not answered concerned tetanus status and administration, delayed p r i m a r y closure, time to dressing removal, and whether patients were asked to r e t u r n for wound checks before suture removal. Responses to demographic questions are listed (Table 1). Respondents who worked clinically spent 41.6 + 13.1 hours p e r week (range, zero to 99 hours) in the ED. Responses to nondemographic questions are listed (Table 2). The results of questions pertaining to wound irrigation, wound soaking, choice of wound dressings, decision to perform delayed p r i m a r y closure, indications for antimicrobial usage, and methods of antimicrobial administration reflect multiple choices by individual respondents for specific questions. F o r example, providers used various methods of wound p r e p a r a t i o n , closure, and chemotherapy with undetermined frequencies. Respondents also gave multiple responses when none were requested. This is true of the questions regarding wound management based on provider preference or a written protocol (ie, the first two responses in Table 2). Respondents wrote in the following answers to various questions. Two respondents used sterile toothbrushes and one used a gloved finger to scrub wound surfaces. Irrigation techniques included fenestrations in the top of normal saline bottles (three), pouring from a bottle or cup (three), and 10mL and 12-mL syringes (three). Reasons for administering IV or oral antimicrobials included the presence of exposed bone, tendon, or joint ( l l ) , wound age (two), immune compromise (two), catfish spines or marine bites (one), and the request of a consultant (one). The decision to suture dog or human bites was influenced by amount of tissue destruction (two) and the ability to easily clean the entire wound (two).
Table 1.
Demographicsof survey respondents Demographic Subheading
No. of Respondents(%)
Board-certified in emergency medicine 97 (64.2) Not beard-cer~ified in medical specialty 32 (21.2) Certified in non-emergency medicine or certified in both emergency medicine and non-emergency specialty 22 (14.6) Emergency medicine practice mostly clinical* 131 (86.8) Emergency medicine practice mostly administrative * 4 (2.6) Affiliated with emergency medicine residency 35 (23.2) Affiliated with teaching, non-emergency medicine residency 27 (17.9) Net affiliated with residency 89 (58.9) Annual emergency medicine census less than 20,0gOpatients 26 (17.2) Annual emergency medicine census 20,000to 50,000 patients 93 (61.6) Annual emergency medicine census more than 50,000 patients 32 (21.2) Physicians spending morethan 50% of professionaltime in a given practice style.
977/103
WOUND
CARE
HoweE& Ch~ho~
Table 2. Responses to nondemographic questions from wound survey No. of Respondent(%) General Written protocol regarding wound preparation Wound care based on individual preference
41 (29)
120 (90)
Tetanus prophylaxis Tetanus status requested by screening personnel (nurse) Tetanus given by nurses as part of initial screening
150 (99) 68 (45)
Wound preparation Provider soaks wounds Frequently Sometimes Infrequently Rarely Unsure Provider soaks wounds with 1% Povidone iodine Normal saline Shur Clens® Hydrogen peroxide 10% Povidone iodine CNorhexidine Antibiotic solution Other Provider scrubs the entire wound Frequently Sometimes Infrequently Rarely Unsure Provider scrubs entire wound using Cotton gauze Coarse, bristle-laden sponge Fine-pore sponge Other Provider scrubs entire wound with 1% Povidone iodine Normal saline Shur Clens® Hibiclens® Hydrogen peroxide 10% Povidone iodine Tap water Phisohex® Other Provider irrigates wounds more than 50% of the time Provider irrigates wounds with Phisohex® Normal saline 1% Povidene iodine Hydrogen peroxide Shur Clens® Hibiclens ® 10% Povidone iodine Tap water Other Provider irrigates wounds using 20- to 3O-mL syringe with plastic cathether Bulb syringe Spring-loaded syringe with cathether kit IV solution through IV tubing with pressure cuff IV solution through IV tubing without pressure cuff Other
104/978
No. ofResponden~(%) Wound closure
20 (13) 38 (25) 34 (22) 38 (25) 21 (14) 95 (74) 55 (43) 16 (13) 15(12) 11 (9)
5 (6) 2 (2) lO (8) 88 (45) 33 (22) 26 (17) 16(11)
8 (5) s3 (59) 54 (38) 53 (37) 5 (4) 83 (59) 79 (56) 37 (26) 35 (25) 19(13) 16(11) 5 (4) 6 (4) 3 (2) 113 (75) 151 (100) 143 (95) 32 (21) 11 (7) 7 (5)
6 (4) 4 (3) 1(1) 5 (3) 127 (85) 22 (15) 18 (12) 10 (7) 8 (5) 20 (13)
Provider sutures dog bite wounds More than 75% ofthe time 26% to 74% of the time 5% te 25% of the time 1% to 4% of the time Not at all Decision to suture dog bite wounds is influenced by Anatomic location Cosmetic effect Wound depth Size of dog Other Provider sutures human bite wounds More than 75% of the time 28% to 74% of the time r 5% to 25% of the time 1% to 4% ofthe time Not at all Decision to suture human bite wounds is influenced by Cosmetic effect Anatomic location Wound depth Other
41 (27) 59 (39) 25 (17) 23 (15) 3 (2) 137 (93) 131 (89) 85 (58) 4 (3) 12 (8) 4 (3) 25 (17) 27 (18) 58 (38) 37 (25) 131 (89) 92 (77) 53 (45) 8 (7)
Wound dressings and follow-up Most dressings placed on simple lacerations are Gauze and an antimicrobial product (is, Bacitracin ® Simple, dry gauze Petrolatum-impregnated gauze (is, Xeroform®) Bio-occlusivedressing(ie, Tegoderm®) Other Patients instructed to take dressings off in Lessthan one day One day Two days Three days Four days More than four days Providers asks what percentage of patients to have wound check before suture removal Less than 25% 25% to 50% 51% to 75% Mere than 75% Wound follow-up is performed more than 50% of the time In my ED With primary provider Outpatient clinic, unspecified provider Outpatient clinic, specified provider Other
106 (71) 30 (20) 28 (19) 4 (3) 7 (5) 0 (g) 4 (3) 65 (44) 74 (50) 6 (4) 0 (O)
61 (41) 38 (25) 14 (9) 37 (25) 80 (54) 57 (39) 4 i3) 5 (3) 1 (1)
Delayed primary closure (DPC) DPC is performed in what percentage of patients Never 1% to 5% 6% to 10% 11% to 20% 21% to 25% More than 25%
ANNALS OF EMERGENCY MEDrCINE
18 (12) 92 (64) 24 (17) 4 (3) 5 (4) 0 (0)
21:8
AUGUST1992
W O U N D CARE Howell & Chisholm
Table2. Responses to nondemographic questions from wound survey (continued)
No. ofRespondents(%) Indications for DPC include Wound contamination 107 (74) Age of wound 112 (71) Human bites 79 (55) Mechanism of injury 64 (44) Dog bites 59 (41) Cat bites 55 (38) Possible foreign body 40 (28) Uncooperative, intoxicated patient 34 (23) Other bites 30 (21) Immune compromise 27 (19) Do not use BPC 27 (19) Decision to perform DPC influenced by Anatomic location of wound 95 (85) Cosmetic impact 87 (78) Wound depth 57 (51) Other 11 (10) Wounds prepared for DPC in the ED are usually followed for closure by Plastic or general surgeon 87 (69) My ED 42 (33) A primary care physician 6 (5) Other 6 (5) Patients prepared for DPC are instructed to be seen by a physician in 24 hours or less 84 (52) 25to 36 hours 23 (19) 37 to 48 hours 22 (18) 49t0 72 hours 12 (10) Morethan 72 hours 1 (1) DPC patients are placed on antibiotics More than 75% of the time 80 (64) 26% to 74% of the time 26 (21) 5% to 25% of the time 9 (7) 1%to4% ofthetime 9 (7) Not at all 1 (1)
Antibiotictherapy indications for IV antibiotics in acute, noninfected wounds (ie, prophylaxis)include Simple lacerations 6rossly contaminated wounds Human bites (closed-fist injury) Human bites (other) Cat bites Do not use IV antibiotics Dog bites Hand lacerations Foot puncture wounds Complex lacerations Foot lacerations Other
AUGUST1992
21:8
ANNALS OF EMERGENCY MEDICINE
149 (100) 93 (62) 88 (59) 52 (35) 44 (30) 39 (26) 29 (20) 17 (11) 14 (9) 11 (7) 7 (5) 22 (15)
No. of Respondents(%) Provider uses antibiotics by mouth for acute, noninfect~d wounds (ie, prophylaxis) More than 75% of the time 26% to 74% of the time 5% to 25% of the time 1% to 4% of the time Not at all Indications for oral antibiotics for acute, noninfected wounds (ie, prophylaxis) include Cat bites Human bites (closed-fist injury) Human bites (other) Dog bites Grossly contaminated wounds Foot puncture w9unds Hand lacerations Complex lacerations Foot lacerations Other Simple lacerations Do not use oral antibiotics Provider prescribes oral antibiotics for acute, noninfected dog bite wounds Deep wounds (below dermis) For all such wounds Based on location antibiotics for this indication Do not routinely prescribe oral antibiotics for this indication Only for sutured wounds When cosmesis is important Provider prescribes oral antibiotics for acute, noninfected human bite wounds For all such wounds Deep wounds (below dermis) Based on location Onlyfor sutured wounds When cosmesis is important Do not routinely prescribe oral antibiotics for this indication
7 (5) 49 (33) 67 (44) 25 (17) 2 (1)
137 (91) 133 (89) 128 (85) 114 (76) 108 (72) 73 (49) 36 (24) 29 (19) 27 (18) 13 (9) 1 (1) 0 (0)
55 (37) 54 (36) 25 (17) 25 (17) 15 (10) 4 (3)
96 (64) 34 (22) 26 (17) 9 (6) 7 (5) 5 (3)
Anagelsia Provider prescribes analgesics other than salicylates (ie, NSAIDs, narcotics, other) for patients with simple lacerations, punctures, or bites More than 75% of the time 26% to 74% of the time 5%to 25% of the time 1% to 4% of the time Not at all
6 (4) 27 (19) 47 (31) 48 (31) 23 (15)
979/105
WOUND 6ABE Howell & Chisholm
DISCUSSION
Although infection rates for most outpatient wounds are small, 1 the frequency with which wounding occurs makes this problem significant in terms of clinical morbidity, disability, and consequent socioeconomic impact. In general, the examination, p r e p a r a t i o n , and definitive treatment of outpatient wounds are based on either p r o v i d e r experience or a limited number of clinical studies with inadequate statistical power to detect small differences among low complication rates. Consequently, there is significant variation among methods of treatment, and national wound care standards have not been developed. Our survey found, for example, that only 29% of respondents had a written protocol regarding wound p r e p a r a t i o n and that 90% cared for wounds based on individual preference. We presume 19% used individual preference despite written protocols. Wound preparations varied with respect to soaking, scrubbing, and irrigation. Thirty-eight percent soaked wounds either "sometimes" (ie, 26% to 74% of the time) or "frequently" (ie, more than 75% of the time). Lammers et al 3 showed that soaking heavily contaminated wounds with 1% providone iodine or normal saline either had no effect or increased bacterial counts p e r gram of wounded tissue. The effect of soaking wounds on ultimate outcome has not been studied. Sixtyseven percent of physicians polled in our study scrubbed woUnds either sometimes or frequently, using cotton gauze (59%) and a coarse, bristle-laden sponge (38%). The use of scrubbing acute traumatic wounds is debatable,a, 5 and p a r ticular methods of scrubbing wounds have not been evaluated scientifically. Although 75% of surveyed providers irrigated wounds, many used techniques that have not been proven to generate the minimum 5 to 8 psi considered appropriate for tissue cleansing. 6-8 Antiseptic solutions used to clean wounds varied among practitioners: 25% scrubbed with chlorhexidine, 13% used hydrogen peroxide, 11% used a 10% povidone iodine solution, and 4% used hexachlorophene. All the respondents reported using hexachlorophene at one time or another to irrigate wounds. Animal studies suggest these solutions may be injurious to host tissue. 9-12 In particular, full-strength hydrogen peroxide injures fibroblasts i n v i t r o 13 and occludes local microvasculature. 9 Providers were more likely to suture dog bites than human bites. Whereas 66% closed dog bites more than 25% of the time, only 20% sutured human bites with the same frequency. One series of human bite wounds 14 documented an infection rate of less than 3% once "closed-fist injuries" were excluded. Conversely, P a l m e r and Rees is found a 14.7% infection rate among facial dog bites in a large retrospective review. The clinical concern about infection and human bites pertains mostly to lacerations overlying metacarpophalangeal joints, or so-called closed-fist injuries. These injuries may lead to tenosynovitis, septic arthritis, and osteomyehtis. However, there are no clinical data to support limiting clo-
106/990
sure of all human bites, even though there is theoretical concern regarding their proliferative microbiology. One a p p r o a c h to the contaminated wound is delayed prim a r y closure. Delayed p r i m a r y closure 12 is ~ technique whereby wounds likely to become infected are p r e p a r e d for surgical closure and then sutured 48 to 96 hours after wounding. P r o p e r wound p r e p a r a t i o n diminishes microbial concentrations in the wound, which in t u r n allows delayed closure when bacterial counts fall to lower levels. Twelve percent of respondents never performed delayed p r i m a r y closure, and 64% used this technique less than 6% of the time. Considering the potential for diminishing infection rates among contaminated wounds 16 with infection rates higher than 5% to 6%, it is interesting this technique is not used more frequently. Wound dressingsincluded petrolatum-impregnated gauze (19%), d r y gauze dressings (20%), an antimicrobial product (71%), and bio-occlusive dressings (3%). Variability in wound dressings again reflects the divergent literature on this subject. Dire et aP 7 showed that applying Neosporin ® or Bacitracin ® ointment resulted in lower infection rates comp a r e d with silver sulfadiazine or petrolatum. Some physicians 12 recommend moist dressings because they may facilitate epithehalization, whereas others prefer d r y dressings, especially in the area of b u r n care. No studies have compared d r y dressings with ointments or petrolatum in acute, traumatic, outpatient wounds. The use of antimicrobials appears to be widespread. All respondents administered prophylactic IV antimicrobials at one time or another for simple noninfected lacerations. We did not ask respondents to identify the frequency of this practice, and we presume it is infrequent. Several studies ls-20 suggest that prophylactic, systemic antimicrobials are ineffective in preventing wound infection in simple lacerations. No study has evaluated the effectiveness of IV antimicrobials in preventing wound infection after simple lacerations. However, some authors 12 recommend the use of IV antimicrobials for infection-prone wounds because oral antimicrobials are a b s o r b e d erratically from the intestines, and early formation of a coagnlum a r o u n d bacteria could theoretically protect them from antimicrobial chemotherapy. Suggested indications for antimicrobial t h e r a p y of acute traumatic wounds are available elsewhere. 21 Our survey had limitations. Selection bias could have occurred because the sample was composed entirely of emergency physicians from ACEP and did not include all physicians who treat outpatient wounds. F u r t h e r , survey respondents p r o b a b l y take an active interest in wound care because they took time to complete an extensive survey. However, we sampled physicians with a b r o a d mix of b o a r d certifications, practice styles, and annual censuses.
ANNALS 0F EMERGENCY MEDICINE 21:8
AUGUST1992
WOUND CARE Howell & Chisholm
CONCLUSION
REFERENCES
We report the results of a survey mailed to emergency physicians regarding the care of acute traumatic wounds in the outpatient setting. Methods of preparing, treating, and following these injuries varied significantly among physicians polled. Even a select physician population with assumed interest and experience in wound care (ie, ACEP members) demonstrated tremendous variability in virtually all aspects of outpatient wound management. This widespread variability in practice styles may emanate from inadequate quality research combined with a lack of graduate and postgraduate medical training in this area. Clinical standards being developed by ACEP should take into account the tremendous variability in current clinical practice identified here. Interested physicians should undertake further research and education in wound cleansing, closure decisions, and the optimal use of antimicrobials.
1. Simon B: Treatment of wounds, in Rosen P, et al (eds): Emergency Medicine: Concepts and Clinical Practice, ed 2. St Louis, CV Mosby, 1988, p 363-373.
8. Gross R, Outright DE, Bhasker SN: Effectiveness of pulsating water jet lavage in treatment of contaminated crush wounds. Am J Surg 1972;124:373-375.
Theauthors thank Everett Logue, PhD, for his statistical analysis of the data.
9. Branemark PI, Ekholm R, Albrektsson B, et al: Tissue injury caused by wound disinfectants. J Bone Joint Surg 1967;49A:48-62.
2. Bucknall TE: The effect of local infection upon wound hea!ing: An experimental study. Br J Surg 1980;67:851. 3. Lammers RL, Fourr'e M, Callaharn ML, et al: Effect of povidene-iodine and saline soaking on bacterial counts in acute, traumatic, contaminated wounds. Ann ErnergMed 1990;t9:709-714. 4. Gingrass RP: Effect of various topical preparations on preventien of infection in experimental contaminated wounds. J Trauma 1964;4:763-783. 5. Foster JD: A trial of scrubbing sutured lacerations (letter). Ann Emerg Med 1988;17:386-387. 6. Wheeler CB, Radeheaver 6T, Thacker J6, et al: Side effects of high pressure irrigation. Surg Obstet Gyneco11976;t43:775-778. 7. Stevenson TR, Thacker JG, Rodeheaver 6T, et al: Cleansing the traumatic wound by high pressure irrigation. JACEP 1976;5:17-21.
10. Custer J, Edlich RF, Prusak M, et al: Studies in the management of the contaminated wound. Am J Surg 1971;122:572-575. 11. Vilhanto J: Disinfection of surgical wounds without inhibition of normal wound healing. Arch Surg 1980;115:253-256. 12. Edlich RF, Rodeheaver GT, Morgan RF, et al: Principles of emergency wound management. Ann Emerg Med 1988;17:1284-1302. 13. Lineweever W, Howard R, Saucy D, et al: Topical antimicrobial toxicity. Arch Surg 1985;120:267-270. 14. Earley MJ, Bardsley AF: Human bites: A review. BrJ PlastSurg 1984;37:458-462. 15. Palmer J, Rees M: Dog bites of the face: A 15 year review. J PlastSurg 1983;36:315318, 16. Edlich RF, Thacker J6, Rodeheaver 6T: Wound management and skin closure, in Harwood-Nuss A, Linden OH, Luten RC, et al (eds): The Clinical Practice of Emergency Medicine. Philadelphia, JB Lippincott, 1991, p 320-332. 17. Dire DJ, Coppola M, Dwyer DA, et al: A prospective evaluation of topical antibiotics for uncomplicated soft-tissue lacerations (abstract). Ann Emerg Med 1991;20:451. 18. Thirlby RC, Blair A J, Thai ER: The value of prophylactic antibiotics for simple lacerations. Surg Gynecol Obstet 1983;156:212-216. 19. Hutton PA, Jones CM, Law DJ: Depot penicillin as prophylaxis in accidental wounds. Br J Surg 1978;65:549. 20. Haughey RE, Lammers RL, Wagner DK: Use of antibiotics in the initial management of soft tissue hand wounds. Ann Emerg Med 1981;10:187. 21. Edlich RF, Kenney J6, Morgan RF, et al: Antimierobial treatment of minor soft tissue lacerations: A critical review. Emerg Med Olin North Am 1986;4:561-580.
Address for reprints: John M Howell, MD, FACEP,Department of Emergency Medicine, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DO 20007.
AUGUST1992
21:8
ANNALS OF EMERGENCY MEDICINE
981/107
wounds, outpatient
Oatpatient WoundPreparation and Care" A National Survey From Northeastern Ohio Universities College of Medicine, Akron, Ohio;* and Methodist Hospital of Indiana, Inc, and the Indiana University School of Medicine, Indianapolis. t Received for publication November 7, 1991. Revision received February 27, 1992. Accepted for publication April 3, 1992.
John M Howell, MD, FP,CEP* Carey D Chisholm,MD, FACEP*
Study objectives: To sample the practice styles of emergency physicians caring for acute traumatic wounds.
Design: Written survey. US emergency departments obtained from the American College of Emergency Physicians mailing list. Setting:
Subjects: Randomly selected ACEP members. M a i n results: One hundred fifty-one of 285 (53%) survey mailings were returned. Eighty-six percent of respondents were primarily clinicians, and the majority (61.6%) worked in EDs with annual patient visits between 21,000 and 50,000. The majority of respondents (64.2%) were certified by the American Board of Emergency Medicine. Nineteen percent managed wounds based on provider preference despite the existence of written wound management protocols. We identified a variety of practices that are contrary to current literature and textbook recommendations. Fifty-eight (38%) soaked wounds, whereas 21% used either 10% povidone iodine or hydrogen peroxide to cleanse wounds. One hundred one (67%) scrubbed the entire wound surface using, among other methods, cotton gauze (59%) or a coarse, bristle-laden sponge (38%). Forty (27%) irrigated wounds using techniques that have not been proven to deliver the 5 to 8 psi necessary for adequate tissue cleansing. Delayed primary closure, a treatment option for lacerations at increased risk for infection, was infrequently or never practiced by 76% of respondents. All respondents administered IV antimicrobials at least occasionally for simple outpatient lacerations. Conclusion: Methods of preparing, treating, and following outpatient wounds vary among emergency physicians, and these results support the idea that no de factostandard of care exists for this clinical problem. Outpatient wound care techniques routinely practiced {ie, soaking, scrubbing, use of full-strength hydrogen peroxide or fullstrength povidone iodine) may be harmful based on limited animal and human research, whereas other proven techniques (ie, delayed primary closure) are infrequently practiced by many emergency physicians. [Howell JM, Chisholm CD: Outpatient wound preparation and care: A national survey. Ann EmergMedAugust1992;21:976:981 .]
102/976
ANNALS OF EMERGENCYMEDICINE 21:8 AUGUST1992
WOUND CARE
Howell& Chisholm
INTRODUCTION
Approximately ten million patients with traumatic wounds are treated annually in US emergency departments.1 Wound infections occur in fewer than 10% of emergency patients, but when they occur they have a deleterious effect on healing, tissue strength, and cosmesis. 2 P r o p e r wound p r e p a r a tion and closure should diminish suppurative complications. However, a standardized a p p r o a c h to the care of outpatient traumatic wounds has yet to be established, in p a r t because of a paucity of statistically powerful clinical studies. This is compounded because few medical schools devote formal and standardized curricula to wound healing and management: Thus, we believe most practitioners in the United States use personal experience and preference when caring for outpatient wounds and that a de f a c t o s t a n d a r d of care does not exist. Using a survey format, we obtained information regarding tetanus prophylaxis and the p r e p a r a t i o n , cleansing, closure, dressing, follow-up, and antimicrobial and analgesic t h e r a p y of outpatient traumatic wounds treated by emergency physicians. The purpose of gathering this information was to identify variations in methods of treatment to serve as targets for research. MATERIALS
AND
METHODS
We mailed the survey in March 1991; the authors wrote the survey in consultation with a statistician. Before mailing, the survey was administered to four American B o a r d of Emergency Medicine-certified attending and four resident level emergency physicians. After this initial validation process, minor changes were made in the wording of the survey to ensure clarity and accuracy. Several closed questions asked respondents to identify practice frequencies in terms of percentages. F o r example, the term frequently was defined as more than 75% frequency; sometimes, 26% to 74%; infrequently, less than 25%; rarely, less than 5%. The names and addresses of 285 emergency physicians were generated randomly from the membership list of the American College of Emergency Physicians. A cover letter from the president of ACEP encouraged participation. The denominator used to calculate the percentage of positive respondents was the number of respondents to each question and not the total number of surveys returned. F o r many questions regarding methods of treatment, respondents were instructed to choose as many answers as were applicable. For example, many providers chose several different soaking or irrigation solutions, which they apparently use at different times. Under a limited n u m b e r of questions, respondents were asked to write " o t h e r " answers where appropriate. Bhnded data entry was performed and descriptive statistics were generated for each response.
AUGUST1992
21:8
ANNALS OF EMERGENCY MEDICINE
RESULTS We received 151 responses to 285 survey mailings (53%). Seven of 39 questions (18%) were not answered with varying frequencies. The mean number of nonrespondents to each unanswered question was 9.85 + 10.44, with a range of one to 29. The questions not answered concerned tetanus status and administration, delayed p r i m a r y closure, time to dressing removal, and whether patients were asked to r e t u r n for wound checks before suture removal. Responses to demographic questions are listed (Table 1). Respondents who worked clinically spent 41.6 + 13.1 hours p e r week (range, zero to 99 hours) in the ED. Responses to nondemographic questions are listed (Table 2). The results of questions pertaining to wound irrigation, wound soaking, choice of wound dressings, decision to perform delayed p r i m a r y closure, indications for antimicrobial usage, and methods of antimicrobial administration reflect multiple choices by individual respondents for specific questions. F o r example, providers used various methods of wound p r e p a r a t i o n , closure, and chemotherapy with undetermined frequencies. Respondents also gave multiple responses when none were requested. This is true of the questions regarding wound management based on provider preference or a written protocol (ie, the first two responses in Table 2). Respondents wrote in the following answers to various questions. Two respondents used sterile toothbrushes and one used a gloved finger to scrub wound surfaces. Irrigation techniques included fenestrations in the top of normal saline bottles (three), pouring from a bottle or cup (three), and 10mL and 12-mL syringes (three). Reasons for administering IV or oral antimicrobials included the presence of exposed bone, tendon, or joint ( l l ) , wound age (two), immune compromise (two), catfish spines or marine bites (one), and the request of a consultant (one). The decision to suture dog or human bites was influenced by amount of tissue destruction (two) and the ability to easily clean the entire wound (two).
Table 1.
Demographicsof survey respondents Demographic Subheading
No. of Respondents(%)
Board-certified in emergency medicine 97 (64.2) Not beard-cer~ified in medical specialty 32 (21.2) Certified in non-emergency medicine or certified in both emergency medicine and non-emergency specialty 22 (14.6) Emergency medicine practice mostly clinical* 131 (86.8) Emergency medicine practice mostly administrative * 4 (2.6) Affiliated with emergency medicine residency 35 (23.2) Affiliated with teaching, non-emergency medicine residency 27 (17.9) Net affiliated with residency 89 (58.9) Annual emergency medicine census less than 20,0gOpatients 26 (17.2) Annual emergency medicine census 20,000to 50,000 patients 93 (61.6) Annual emergency medicine census more than 50,000 patients 32 (21.2) Physicians spending morethan 50% of professionaltime in a given practice style.
977/103
WOUND
CARE
HoweE& Ch~ho~
Table 2. Responses to nondemographic questions from wound survey No. of Respondent(%) General Written protocol regarding wound preparation Wound care based on individual preference
41 (29)
120 (90)
Tetanus prophylaxis Tetanus status requested by screening personnel (nurse) Tetanus given by nurses as part of initial screening
150 (99) 68 (45)
Wound preparation Provider soaks wounds Frequently Sometimes Infrequently Rarely Unsure Provider soaks wounds with 1% Povidone iodine Normal saline Shur Clens® Hydrogen peroxide 10% Povidone iodine CNorhexidine Antibiotic solution Other Provider scrubs the entire wound Frequently Sometimes Infrequently Rarely Unsure Provider scrubs entire wound using Cotton gauze Coarse, bristle-laden sponge Fine-pore sponge Other Provider scrubs entire wound with 1% Povidone iodine Normal saline Shur Clens® Hibiclens® Hydrogen peroxide 10% Povidone iodine Tap water Phisohex® Other Provider irrigates wounds more than 50% of the time Provider irrigates wounds with Phisohex® Normal saline 1% Povidene iodine Hydrogen peroxide Shur Clens® Hibiclens ® 10% Povidone iodine Tap water Other Provider irrigates wounds using 20- to 3O-mL syringe with plastic cathether Bulb syringe Spring-loaded syringe with cathether kit IV solution through IV tubing with pressure cuff IV solution through IV tubing without pressure cuff Other
104/978
No. ofResponden~(%) Wound closure
20 (13) 38 (25) 34 (22) 38 (25) 21 (14) 95 (74) 55 (43) 16 (13) 15(12) 11 (9)
5 (6) 2 (2) lO (8) 88 (45) 33 (22) 26 (17) 16(11)
8 (5) s3 (59) 54 (38) 53 (37) 5 (4) 83 (59) 79 (56) 37 (26) 35 (25) 19(13) 16(11) 5 (4) 6 (4) 3 (2) 113 (75) 151 (100) 143 (95) 32 (21) 11 (7) 7 (5)
6 (4) 4 (3) 1(1) 5 (3) 127 (85) 22 (15) 18 (12) 10 (7) 8 (5) 20 (13)
Provider sutures dog bite wounds More than 75% ofthe time 26% to 74% of the time 5% te 25% of the time 1% to 4% of the time Not at all Decision to suture dog bite wounds is influenced by Anatomic location Cosmetic effect Wound depth Size of dog Other Provider sutures human bite wounds More than 75% of the time 28% to 74% of the time r 5% to 25% of the time 1% to 4% ofthe time Not at all Decision to suture human bite wounds is influenced by Cosmetic effect Anatomic location Wound depth Other
41 (27) 59 (39) 25 (17) 23 (15) 3 (2) 137 (93) 131 (89) 85 (58) 4 (3) 12 (8) 4 (3) 25 (17) 27 (18) 58 (38) 37 (25) 131 (89) 92 (77) 53 (45) 8 (7)
Wound dressings and follow-up Most dressings placed on simple lacerations are Gauze and an antimicrobial product (is, Bacitracin ® Simple, dry gauze Petrolatum-impregnated gauze (is, Xeroform®) Bio-occlusivedressing(ie, Tegoderm®) Other Patients instructed to take dressings off in Lessthan one day One day Two days Three days Four days More than four days Providers asks what percentage of patients to have wound check before suture removal Less than 25% 25% to 50% 51% to 75% Mere than 75% Wound follow-up is performed more than 50% of the time In my ED With primary provider Outpatient clinic, unspecified provider Outpatient clinic, specified provider Other
106 (71) 30 (20) 28 (19) 4 (3) 7 (5) 0 (g) 4 (3) 65 (44) 74 (50) 6 (4) 0 (O)
61 (41) 38 (25) 14 (9) 37 (25) 80 (54) 57 (39) 4 i3) 5 (3) 1 (1)
Delayed primary closure (DPC) DPC is performed in what percentage of patients Never 1% to 5% 6% to 10% 11% to 20% 21% to 25% More than 25%
ANNALS OF EMERGENCY MEDrCINE
18 (12) 92 (64) 24 (17) 4 (3) 5 (4) 0 (0)
21:8
AUGUST1992
W O U N D CARE Howell & Chisholm
Table2. Responses to nondemographic questions from wound survey (continued)
No. ofRespondents(%) Indications for DPC include Wound contamination 107 (74) Age of wound 112 (71) Human bites 79 (55) Mechanism of injury 64 (44) Dog bites 59 (41) Cat bites 55 (38) Possible foreign body 40 (28) Uncooperative, intoxicated patient 34 (23) Other bites 30 (21) Immune compromise 27 (19) Do not use BPC 27 (19) Decision to perform DPC influenced by Anatomic location of wound 95 (85) Cosmetic impact 87 (78) Wound depth 57 (51) Other 11 (10) Wounds prepared for DPC in the ED are usually followed for closure by Plastic or general surgeon 87 (69) My ED 42 (33) A primary care physician 6 (5) Other 6 (5) Patients prepared for DPC are instructed to be seen by a physician in 24 hours or less 84 (52) 25to 36 hours 23 (19) 37 to 48 hours 22 (18) 49t0 72 hours 12 (10) Morethan 72 hours 1 (1) DPC patients are placed on antibiotics More than 75% of the time 80 (64) 26% to 74% of the time 26 (21) 5% to 25% of the time 9 (7) 1%to4% ofthetime 9 (7) Not at all 1 (1)
Antibiotictherapy indications for IV antibiotics in acute, noninfected wounds (ie, prophylaxis)include Simple lacerations 6rossly contaminated wounds Human bites (closed-fist injury) Human bites (other) Cat bites Do not use IV antibiotics Dog bites Hand lacerations Foot puncture wounds Complex lacerations Foot lacerations Other
AUGUST1992
21:8
ANNALS OF EMERGENCY MEDICINE
149 (100) 93 (62) 88 (59) 52 (35) 44 (30) 39 (26) 29 (20) 17 (11) 14 (9) 11 (7) 7 (5) 22 (15)
No. of Respondents(%) Provider uses antibiotics by mouth for acute, noninfect~d wounds (ie, prophylaxis) More than 75% of the time 26% to 74% of the time 5% to 25% of the time 1% to 4% of the time Not at all Indications for oral antibiotics for acute, noninfected wounds (ie, prophylaxis) include Cat bites Human bites (closed-fist injury) Human bites (other) Dog bites Grossly contaminated wounds Foot puncture w9unds Hand lacerations Complex lacerations Foot lacerations Other Simple lacerations Do not use oral antibiotics Provider prescribes oral antibiotics for acute, noninfected dog bite wounds Deep wounds (below dermis) For all such wounds Based on location antibiotics for this indication Do not routinely prescribe oral antibiotics for this indication Only for sutured wounds When cosmesis is important Provider prescribes oral antibiotics for acute, noninfected human bite wounds For all such wounds Deep wounds (below dermis) Based on location Onlyfor sutured wounds When cosmesis is important Do not routinely prescribe oral antibiotics for this indication
7 (5) 49 (33) 67 (44) 25 (17) 2 (1)
137 (91) 133 (89) 128 (85) 114 (76) 108 (72) 73 (49) 36 (24) 29 (19) 27 (18) 13 (9) 1 (1) 0 (0)
55 (37) 54 (36) 25 (17) 25 (17) 15 (10) 4 (3)
96 (64) 34 (22) 26 (17) 9 (6) 7 (5) 5 (3)
Anagelsia Provider prescribes analgesics other than salicylates (ie, NSAIDs, narcotics, other) for patients with simple lacerations, punctures, or bites More than 75% of the time 26% to 74% of the time 5%to 25% of the time 1% to 4% of the time Not at all
6 (4) 27 (19) 47 (31) 48 (31) 23 (15)
979/105
WOUND 6ABE Howell & Chisholm
DISCUSSION
Although infection rates for most outpatient wounds are small, 1 the frequency with which wounding occurs makes this problem significant in terms of clinical morbidity, disability, and consequent socioeconomic impact. In general, the examination, p r e p a r a t i o n , and definitive treatment of outpatient wounds are based on either p r o v i d e r experience or a limited number of clinical studies with inadequate statistical power to detect small differences among low complication rates. Consequently, there is significant variation among methods of treatment, and national wound care standards have not been developed. Our survey found, for example, that only 29% of respondents had a written protocol regarding wound p r e p a r a t i o n and that 90% cared for wounds based on individual preference. We presume 19% used individual preference despite written protocols. Wound preparations varied with respect to soaking, scrubbing, and irrigation. Thirty-eight percent soaked wounds either "sometimes" (ie, 26% to 74% of the time) or "frequently" (ie, more than 75% of the time). Lammers et al 3 showed that soaking heavily contaminated wounds with 1% providone iodine or normal saline either had no effect or increased bacterial counts p e r gram of wounded tissue. The effect of soaking wounds on ultimate outcome has not been studied. Sixtyseven percent of physicians polled in our study scrubbed woUnds either sometimes or frequently, using cotton gauze (59%) and a coarse, bristle-laden sponge (38%). The use of scrubbing acute traumatic wounds is debatable,a, 5 and p a r ticular methods of scrubbing wounds have not been evaluated scientifically. Although 75% of surveyed providers irrigated wounds, many used techniques that have not been proven to generate the minimum 5 to 8 psi considered appropriate for tissue cleansing. 6-8 Antiseptic solutions used to clean wounds varied among practitioners: 25% scrubbed with chlorhexidine, 13% used hydrogen peroxide, 11% used a 10% povidone iodine solution, and 4% used hexachlorophene. All the respondents reported using hexachlorophene at one time or another to irrigate wounds. Animal studies suggest these solutions may be injurious to host tissue. 9-12 In particular, full-strength hydrogen peroxide injures fibroblasts i n v i t r o 13 and occludes local microvasculature. 9 Providers were more likely to suture dog bites than human bites. Whereas 66% closed dog bites more than 25% of the time, only 20% sutured human bites with the same frequency. One series of human bite wounds 14 documented an infection rate of less than 3% once "closed-fist injuries" were excluded. Conversely, P a l m e r and Rees is found a 14.7% infection rate among facial dog bites in a large retrospective review. The clinical concern about infection and human bites pertains mostly to lacerations overlying metacarpophalangeal joints, or so-called closed-fist injuries. These injuries may lead to tenosynovitis, septic arthritis, and osteomyehtis. However, there are no clinical data to support limiting clo-
106/990
sure of all human bites, even though there is theoretical concern regarding their proliferative microbiology. One a p p r o a c h to the contaminated wound is delayed prim a r y closure. Delayed p r i m a r y closure 12 is ~ technique whereby wounds likely to become infected are p r e p a r e d for surgical closure and then sutured 48 to 96 hours after wounding. P r o p e r wound p r e p a r a t i o n diminishes microbial concentrations in the wound, which in t u r n allows delayed closure when bacterial counts fall to lower levels. Twelve percent of respondents never performed delayed p r i m a r y closure, and 64% used this technique less than 6% of the time. Considering the potential for diminishing infection rates among contaminated wounds 16 with infection rates higher than 5% to 6%, it is interesting this technique is not used more frequently. Wound dressingsincluded petrolatum-impregnated gauze (19%), d r y gauze dressings (20%), an antimicrobial product (71%), and bio-occlusive dressings (3%). Variability in wound dressings again reflects the divergent literature on this subject. Dire et aP 7 showed that applying Neosporin ® or Bacitracin ® ointment resulted in lower infection rates comp a r e d with silver sulfadiazine or petrolatum. Some physicians 12 recommend moist dressings because they may facilitate epithehalization, whereas others prefer d r y dressings, especially in the area of b u r n care. No studies have compared d r y dressings with ointments or petrolatum in acute, traumatic, outpatient wounds. The use of antimicrobials appears to be widespread. All respondents administered prophylactic IV antimicrobials at one time or another for simple noninfected lacerations. We did not ask respondents to identify the frequency of this practice, and we presume it is infrequent. Several studies ls-20 suggest that prophylactic, systemic antimicrobials are ineffective in preventing wound infection in simple lacerations. No study has evaluated the effectiveness of IV antimicrobials in preventing wound infection after simple lacerations. However, some authors 12 recommend the use of IV antimicrobials for infection-prone wounds because oral antimicrobials are a b s o r b e d erratically from the intestines, and early formation of a coagnlum a r o u n d bacteria could theoretically protect them from antimicrobial chemotherapy. Suggested indications for antimicrobial t h e r a p y of acute traumatic wounds are available elsewhere. 21 Our survey had limitations. Selection bias could have occurred because the sample was composed entirely of emergency physicians from ACEP and did not include all physicians who treat outpatient wounds. F u r t h e r , survey respondents p r o b a b l y take an active interest in wound care because they took time to complete an extensive survey. However, we sampled physicians with a b r o a d mix of b o a r d certifications, practice styles, and annual censuses.
ANNALS 0F EMERGENCY MEDICINE 21:8
AUGUST1992
WOUND CARE Howell & Chisholm
CONCLUSION
REFERENCES
We report the results of a survey mailed to emergency physicians regarding the care of acute traumatic wounds in the outpatient setting. Methods of preparing, treating, and following these injuries varied significantly among physicians polled. Even a select physician population with assumed interest and experience in wound care (ie, ACEP members) demonstrated tremendous variability in virtually all aspects of outpatient wound management. This widespread variability in practice styles may emanate from inadequate quality research combined with a lack of graduate and postgraduate medical training in this area. Clinical standards being developed by ACEP should take into account the tremendous variability in current clinical practice identified here. Interested physicians should undertake further research and education in wound cleansing, closure decisions, and the optimal use of antimicrobials.
1. Simon B: Treatment of wounds, in Rosen P, et al (eds): Emergency Medicine: Concepts and Clinical Practice, ed 2. St Louis, CV Mosby, 1988, p 363-373.
8. Gross R, Outright DE, Bhasker SN: Effectiveness of pulsating water jet lavage in treatment of contaminated crush wounds. Am J Surg 1972;124:373-375.
Theauthors thank Everett Logue, PhD, for his statistical analysis of the data.
9. Branemark PI, Ekholm R, Albrektsson B, et al: Tissue injury caused by wound disinfectants. J Bone Joint Surg 1967;49A:48-62.
2. Bucknall TE: The effect of local infection upon wound hea!ing: An experimental study. Br J Surg 1980;67:851. 3. Lammers RL, Fourr'e M, Callaharn ML, et al: Effect of povidene-iodine and saline soaking on bacterial counts in acute, traumatic, contaminated wounds. Ann ErnergMed 1990;t9:709-714. 4. Gingrass RP: Effect of various topical preparations on preventien of infection in experimental contaminated wounds. J Trauma 1964;4:763-783. 5. Foster JD: A trial of scrubbing sutured lacerations (letter). Ann Emerg Med 1988;17:386-387. 6. Wheeler CB, Radeheaver 6T, Thacker J6, et al: Side effects of high pressure irrigation. Surg Obstet Gyneco11976;t43:775-778. 7. Stevenson TR, Thacker JG, Rodeheaver 6T, et al: Cleansing the traumatic wound by high pressure irrigation. JACEP 1976;5:17-21.
10. Custer J, Edlich RF, Prusak M, et al: Studies in the management of the contaminated wound. Am J Surg 1971;122:572-575. 11. Vilhanto J: Disinfection of surgical wounds without inhibition of normal wound healing. Arch Surg 1980;115:253-256. 12. Edlich RF, Rodeheaver GT, Morgan RF, et al: Principles of emergency wound management. Ann Emerg Med 1988;17:1284-1302. 13. Lineweever W, Howard R, Saucy D, et al: Topical antimicrobial toxicity. Arch Surg 1985;120:267-270. 14. Earley MJ, Bardsley AF: Human bites: A review. BrJ PlastSurg 1984;37:458-462. 15. Palmer J, Rees M: Dog bites of the face: A 15 year review. J PlastSurg 1983;36:315318, 16. Edlich RF, Thacker J6, Rodeheaver 6T: Wound management and skin closure, in Harwood-Nuss A, Linden OH, Luten RC, et al (eds): The Clinical Practice of Emergency Medicine. Philadelphia, JB Lippincott, 1991, p 320-332. 17. Dire DJ, Coppola M, Dwyer DA, et al: A prospective evaluation of topical antibiotics for uncomplicated soft-tissue lacerations (abstract). Ann Emerg Med 1991;20:451. 18. Thirlby RC, Blair A J, Thai ER: The value of prophylactic antibiotics for simple lacerations. Surg Gynecol Obstet 1983;156:212-216. 19. Hutton PA, Jones CM, Law DJ: Depot penicillin as prophylaxis in accidental wounds. Br J Surg 1978;65:549. 20. Haughey RE, Lammers RL, Wagner DK: Use of antibiotics in the initial management of soft tissue hand wounds. Ann Emerg Med 1981;10:187. 21. Edlich RF, Kenney J6, Morgan RF, et al: Antimierobial treatment of minor soft tissue lacerations: A critical review. Emerg Med Olin North Am 1986;4:561-580.
Address for reprints: John M Howell, MD, FACEP,Department of Emergency Medicine, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DO 20007.
AUGUST1992
21:8
ANNALS OF EMERGENCY MEDICINE
981/107
