Are you giving poor care to high-risk wounds?
Are you giving poor care to high-risk wounds?
A 1 cm uncontaminated cut on the forehead of a healthy child. A 6 cm contused, macerated wound with dirt and gravel on a child’s knee.
How would you care for these two wounds? The former can be cleaned quickly and closed, but the latter needs aggressive numbing, debridement, extensive irrigation, and delayed primary closure, says Tim Wolfe, MD, associate professor for the division of emergency medicine at University of Utah in West Jordan.
Wound location, the patient’s age, and contamination all need to be taken into account, he advises. "One wound may be treated easily with a few squirts of saline, but another wound may need liters of high-pressure irrigation and opening with forceps to clean out properly." (See chart for care of acute and chronic wounds.)
If a patient receives inadequate care of a wound, adverse outcomes may result, adds Wolfe. "If you are the patient who suffers an infection and ends up getting the wound cut open, with intravenous antibiotics, pain, and disfigurement, you will not be happy if you found out you had poor wound care up front," he says.
Patients seeking care for wounds in the ED — especially those with retained foreign bodies, missed tendon injuries, or infections — account for a substantial number of malpractice lawsuits, says Wolfe. "The settlements tend to be relatively low compared to missed myocardial infarction or other more severe issues, but these lawsuits are common," he says.
To avoid infection, do the following:
• Recognize high-risk wounds.
High-risk wounds tend to be on the extremities, especially the knees and elbows, obtained from a fall onto dirt, deep or puncture-like, contaminated, older, and in patients with immune or tissue perfusion dysfunction, including diabetics, patients with renal disease, and obese, immunosuppressed and elderly patients, says Wolfe.
"The more the risks, the higher the chance of infection," he adds.
• Consider delayed primary closure.
With delayed primary closure, "every emergency and trauma specialist should be very familiar with this technique and when it is indicated," says Wolfe.
Patients are instructed not to undress the wound or change the dressing, and on a return visit four days later, the wound is anesthetized, irrigated, and sewn shut as would have been done on the first visit for a clean wound. "This reduces wound infection rates in combat wounds from 30%-50% down to 3%-5% — a 10-times reduction in infection," says Wolfe. "It also results in identical wound outcome in terms of healing and scarring."
• Understand the proper way to irrigate.
The standard of care in the emergency medicine literature is 10-15 pounds per square inch (psi) of irrigation pressure, but some studies have shown that very high volumes of low-pressure irrigation also do well, says Wolfe. "So either high volumes at low to moderate pressures, or adequate volumes at 10-15 psi appear to be optimal," he says.
There is no evidence that use of special wound cleansers make any difference in infection rates, adds Wolfe. "Save the money and spend the time using high-volume/high-pressure irrigation," he recommends.
Studies also show that sterile saline irrigation is no better than tap water, says Wolfe. "I suspect this is because of volume. Tap water probably runs gallons through a wound in the same time you could put just a few squirts of saline through the wound," he says.
Tap water is probably sufficient for low-risk wounds, says Wolfe. "I would be hesitant to recommend the same in a wound near a joint, a deep wound, or a wound in a patient with immune dysfunction."
• Give verbal and written discharge instructions.
If a patient with a high-risk wound was discharged with only verbal instructions and an adverse outcome occurred, the ED nurse and physician could be liable for not providing adequate discharge instructions in the event of a lawsuit, warns Kathryn Eberhart, BSN, RN, CEN, a Santa Rosa, CA-based legal nurse consultant and ED nurse at Santa Rosa Memorial Hospital.
"I have seen a few cases where the discharge instructions were written on the chart by the physician, and the nurses handed them to the patient but failed to provide adequate verbal instructions or make sure the patient understood them," she says.
Review the instructions verbally with the paper in hand, then have the patient sign the instructions to document that they understand them, she advises. Eberhart recommends saying to the patient: By signing this, you acknowledge that you understand the instructions I have explained and given to you. Do you have any questions about those?’
"I’ve seen verbal instructions given by physicians many times over the years. Many times the patients don’t understand the instructions or don’t pay attention to them," she adds.
Since the patient may have questions about wound care at home, Eberhart recommends giving written instructions and verbally reviewing them with the patient. "This way the instructions are documented and a copy is retained by the facility," she says.
Sources/Resource
For more information on wound care in the ED, contact:
- Kathryn Eberhart, BSN, RN, CEN, Eberhart Medical Legal Consulting, 4706 Devonshire Place, Santa Rosa, CA 95405. Telephone: (707) 538-7056. E-mail: [email protected].
- Tim Wolfe, MD, Staff Physician, Emergency Department, Jordan Valley Hospital Jordan Valley Hospital, 3580 West 9000 South, West Jordan, UT 84088. Telephone: (801) 281-3000, ext 102. E-mail: [email protected].
- Canyons Acute Care Wound Irrigation System is a single-patient use, disposable manual irrigation set that delivers high volumes of irrigation at the proper pressure in a short period of time for large wounds, dirty wounds, and trauma patients with multiple wounds. A case of 20 sets costs $186 plus shipping charge depending on quantity and location. To order, contact Wolfe Tory Medical, 79 West 4500 South, Suite 16, Salt Lake City, UT 84107. Telephone: (888) 380-9808 or (801) 281-3000. Web: www.wolfetory.com.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.