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An Educational Intervention to Improve Splinting of Common Hand Injuries
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–7, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.08.011
Original Contributions
AN EDUCATIONAL INTERVENTION TO IMPROVE SPLINTING OF COMMON HAND INJURIES Giancarlo McEvenue, MD, Fiona FitzPatrick, RT (ORTHOPAED), and Herbert P. von Schroeder, MD, MSC, FRCSC University of Toronto Hand Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada Corresponding Address: Herbert P. von Schroeder, MD, MSC, FRCSC, Toronto Western Hospital, 399 Bathurst Street, East Wing 2nd Floor, Toronto, ON M5T 2S8, Canada
, Abstract—Background: Hand trauma is a top presenting complaint to hospital emergency departments (EDs) and can become costly if not treated effectively. The cornerstone for initial management of the traumatized hand is application of a splint. Improving splinting practice could potentially produce tangible benefits in terms of quality of care and costs to society. Objectives: We sought to determine the following: 1) whether the present standard of ED splinting was appropriate and 2) whether a strategically planned educational intervention could improve the existing care. Methods: We used a pre- and postprospective educational intervention study design. In the preintervention phase, patients referred to our hand clinic were assessed for injury and splint type. Splinting appropriateness was evaluated according to a predetermined hand surgeons’ expert consensus. Next, an educational intervention was targeted at all ED staff at our institution. Postintervention, all patients were again evaluated for splint appropriateness. A follow-up evaluation was performed at 1 year to see the long-term effects of the intervention. Results: The most common mechanism of injury of referred patients was falling (35%), and the most frequent injury was metacarpal fracture (40%). Splint appropriateness increased significantly postintervention from 49% to 69% (p = 0.048). At followup after 1 year, splinting appropriateness was 70% (p = 0.041). Conclusion: Appropriate hand splinting practice is essential for hand trauma management. Our results show that an educational intervention can successfully improve splinting practice. This quality of care initiative was low-
cost and demonstrated persistence at 1 year of followup. Ó 2015 Elsevier Inc. , Keywords—education; hand; intervention; splinting; trauma
INTRODUCTION Hand trauma is a common occurrence that accounted for nearly 3.7 million emergency department (ED) visits in the United States in 2008 (1). This injury burden carries with it a subsequent substantial cost in terms of lost work time, income, and disability (2,3). Hand trauma requires appropriate management to minimize issues, such as stiffness, contracture, and dysfunction (4–6). These types of injuries and issues pose a challenge for emergency and primary care physicians because of the complex anatomy and specialized treatment that the hand requires (7,8). Further complicating the matter is the fact that considerable gaps in hand anatomy knowledge exist among doctors working in EDs (9,10). Splinting the traumatized hand is the cornerstone of initial hand trauma management. At our hand clinic, it has been noted anecdotally that many splints applied in the ED are excessively large, involve uninjured parts of the hand, or are not in the optimal ‘‘position of safety’’ (Figure 1). Inappropriate splinting may lead to deleterious outcomes after injury, which may include delayed recovery, a stiff hand, and possibly permanent disability (5,6). As a quality of care improvement initiative we
Reprints are not available from the authors.
RECEIVED: 28 February 2015; FINAL SUBMISSION RECEIVED: 9 July 2015; ACCEPTED: 13 August 2015 1
2
G. McEvenue et al.
Figure 1. Examples of inappropriately splinted hand injuries. (A and B) Excessive splinting of a tuft fracture of the distal phalanx of the ring finger (B, white arrow). (C) A splint for a boxer’s fracture of the fifth metacarpal neck that did not immobilize the injury shown on the same patient’s radiograph (D, arrow).
proposed an educational intervention focused on appropriate splinting of hand trauma in the ED before referral. Educational interventions in health care settings have been shown by others to improve patient outcomes and level of care (11,12). It was our purpose to determine: 1) whether the present standard of ED splinting was appropriate and 2) if strategically planned educational initiatives could improve the existing care. METHODS The setting for this prospective study was a large urban tertiary care teaching hospital that has 2 EDs at separate
geographic sites. It is the normal practice of the institution that all hand injuries are referred to a single hand clinic for follow-up regardless of the magnitude or type of injury. Patients are typically seen in the hand clinic an average of 9 days after their ED visit (range, 1– 36 days). To establish clear guidelines on the appropriateness of splinting practice, 4 experienced fellowship-trained hand surgeons reached a consensus on appropriate splinting for common hand injuries. This included the type of splint, the range of materials, and the anatomic regions to be splinted based on the specific injury diagnoses. From this, a splinting reference chart (Figure 2) was created
Splinting of Common Hand Injuries
3
Figure 2. Splinting reference chart obtained via consensus from 4 fellowship-trained hand surgeons. Indications for splinting are listed in the left column; on the right are appropriate splint types, materials to be used, and a picture for clarity. DIP = distal interphalangeal joint, IP = interphalangeal joint, MCP = metacarpophalangeal joint, PIP = proximal interphalangeal jont, UCL = ulnar collateral ligament
with injury types and the corresponding appropriate splint. The chart included a list of injuries, a description of the preferred splint type, and photographs of representative splints. This chart was re-evaluated by the 4 hand surgeons for final consensus approval. Inappropriate splints were defined as those that positioned the hand incorrectly; unnecessarily immobilized uninjured areas of the extremity; were unnecessarily bulky/flimsy resulting in splint rotation, removal, or loss of reduction; splints that required excessive secondary reinforcement; splints that were too tight resulting in pressure issues or excessive distal swelling; and also injuries that should have been splinted but were not. Patient splint compliance was also recorded, as determined by splint removal or significant modification. A pilot study was conducted to estimate the sample size necessary to sufficiently power our study. A standardized data collection sheet was used to collect all pertinent demographic and splinting data. Pilot data collected over a 2-week period using the splint reference
chart and collection sheet revealed that 50% of patients referred to the Hand Clinic were splinted appropriately. On the basis of this, we designed our study to enroll 45 subjects, yielding 80% power to detect a difference of 25% between the groups before and after the educational intervention (a = 0.05, b = 0.2). The interventional difference was the difference between inappropriate and appropriate splints. The intervention itself was educational in nature and was directed at all those that manage hand trauma acutely at our center (i.e., 50 ED physicians, 2 nurse practitioners, and 6 resident physicians). The information was presented in the form of a lecture series, PowerPoint slides, and a poster outlining common hand injuries and the way to appropriately splint them (Supplementary material). All educational contact and initiatives were recorded for attendance and the date presented. The targets of the intervention were blinded to the purpose and methods of the study. Ethics approval was obtained from our institutional review board and informed consent was obtained from each
4
patient. No patients declined entry to the study. Phase I of the study was performed over a 3-month period in which data were prospectively collected on all adult ED patients referred to the hand clinic. Demographic data, ED diagnoses, and hand clinic diagnoses were recorded. We excluded patients who were <16 years of age, patients with whom we were not able to communicate because of language barriers, carpal or more proximal injuries, and injuries for which the hand service was directly involved during the initial ED management. A photograph of each ED splint was taken and then assessed for appropriateness based on the reference chart. Clinic staff who assessed splints were not directly involved in the study. We allowed for discretion in the decisionmaking of appropriateness for unusual or complicated injuries, but this was only applied on 2 occasions during the study (i.e., for soft tissue injuries where a dorsal splint may have been deleterious to tissue healing). We included patients with injuries that should have been splinted but were not. Phase II was the educational intervention. The intervention phase consisted of 2 PowerPoint lectures of problem-based hand trauma cases, and then one on one teaching sessions with the ED staff involved with hand splinting (i.e., ED doctors, emergency residents, and nurse practitioners). The lecture was provided by the senior author (board certified with added qualification in hand surgery) with live demonstrations of splinting techniques performed by a Registered Orthopaedic Technologist. In addition, 2 half-hour sessions on proper splinting technique were held with ED residents and nurse practitioners. Lecture slides were electronically distributed to all staff. Based on attendance taken at the lectures, we estimate that we were able to directly contact 92% of all the ED staff involved in the treatment of hand injuries. Afterward, we eliminated any barriers to proper splinting by ensuring that only approved splinting materials would be available in the referring EDs. All changes were confirmed before data collection. The last arm of our educational intervention consisted of pocket cards reinforcing the lecture and teaching session information by showing common hand injury diagnoses and recommended splinting techniques (similar to Figure 2). Two large posters (Supplementary material) were placed in each of the 2 EDs in the locations where splinting supplies were located to act as an additional reminder. Six weeks after these educational interventions, phase III data collection began using the same methods as phase I. Differences between groups before and after the educational intervention were analyzed with Prism software (version 6.01; GraphPad Software, La Jolla, CA) using a 2-tailed Fisher’s exact test. As a follow-up to determine the long-term effects of the intervention, data were collected again 1 year later.
G. McEvenue et al.
RESULTS Forty-nine patients were enrolled before the educational intervention and 54 were enrolled after the intervention. The demographic data were similar in both the pre- and postintervention groups (Table 1), with hand injuries occurring in mostly male patients who were in their late 30s. The 2 most common mechanisms of injury were falls on the hand (40% [41/103]) and strikes to the hand (28% [29/103]). Patients who were splinted and who underwent radiography in the ED were unchanged pre- and postintervention. Patient splint compliance, as determined by splint removal or significant modification, improved after intervention from 68% (30/44) to 74% (37/50), respectively, but this was not statistically significant. Diagnostic agreement between the ED and the hand clinic was obtained by comparing the ED referring diagnosis with the hand clinic final diagnosis. This was unchanged in the 2 groups at 78% (38/49) and 79% (43/54), respectively. Splint appropriateness, as determined from criteria based on a consensus of hand surgeon opinion, improved significantly from 49% (24/49) preintervention to 69% (37/ 54) after the educational initiatives (p = 0.048). A final data collection 1 year after the educational initiatives found that the splint appropriateness rate was 70% (35/ 50; p = 0.041).
Table 1. Patient Demographics, Injury, and Splint Appropriateness Pre- and Postintervention Preintervention Postintervention p value Patients (n) Mean age, yrs (SD) Sex Male Female Mechanism of injury, n (%) Crush Strike Fall Penetrating Twist Other Radiograph in ED Splinted in ED Splint compliance Diagnostic agreement Splint appropriateness After 1 year Final diagnosis Phalanx fracture Metacarpal fracture Tendon injury Ligament injury Other
49 36.1 (15.8)
54 39.8 (20.0)
30 (61%) 19 (39%)
34 (63%) 20 (37%)
6 (12%) 16 (33%) 13 (27%) 8 (16%) 2 (4%) 4 (8%) 45/49 (92%) 44/49 (90%) 30/44 (68%) 38/49 (78%) 24/49 (49%)
7 (11%) 13 (20%) 28 (43%) 7 (14%) 3 (5%) 5 (7%) 49/54 (91%) 50/54 (93%) 37/50 (74%) 43/54 (79%) 37/54 (69%) 35/50 (70%)
16 (33%) 20 (41%) 6 (12%) 5 (10%) 2 (4%)
16 (29%) 21 (38%) 6 (11%) 6 (11%) 6 (11%)
ED = Emergency department; SD = standard deviation. * Statistically significant (p < 0.05).
0.29 0.86
1 0.73 0.65 0.81 0.048* 0.041*
Splinting of Common Hand Injuries
DISCUSSION The dissemination of information and implementation of change are challenges that are being increasingly studied in health care (13,14). The success of implementation depends on the specific features of the change proposal, the target group, the setting, and the obstacles encountered to change. Educational interventions to implement quality improvement have been shown to work in the health care setting (11,12). The theory behind our intervention stems from adult learning theories and the intrinsic motivation of professionals to become better at what they do. The strategies this theory advocates are to develop local consensus, use small group interactive learning, and finally problembased learning to achieve the desired change in clinical practice (15). Our intervention was designed using all of these principles. We first developed consensus within our hand surgeon group and then attempted to develop interprofessional consensus across our institution on proper splinting of hand trauma. This collaborative approach was used to focus on the shared goal of better patient care, which is shared by all health care professionals. Our lecture series used a problem-based format on PowerPoint and one on one teaching sessions. Our approach was multifaceted to remove barriers to change and to learning, and to maximize exposure to our standardized splinting regime. To support our choice of educational intervention, a recent review of implementing delirium screening in the intensive care unit found that the most effective educational strategies were multifaceted training, such as lectures, case-based scenarios, one on one teaching, and interdisciplinary communication (16). The targeted area of quality improvement in this study was the technique of splinting for the initial management of hand trauma. Before the intervention, improper splinting rates were unacceptably high. Our intervention was effective by improving appropriate splints significantly from 49% to 69% (p = 0.048). We found almost immediate adoption of the preferred splinting methods because of our collaborative approach and focus on quality improvement. This rapid change may also have been related to the tenet of adult educational theory where change is believed to be driven by an internal striving for professional competence (15). The follow-up analysis of splint appropriateness demonstrated persistence at 70%. Although a decrease effect is possible over time and with changing staff (e.g., rotating residents and the addition of new ED physicians), the posters describing splinting techniques have remained a permanent fixture and have likely helped maintain a high rate of suitable splinting practices. The initiative may require updates, and additional updates have the benefit of being a conduit to introduce other
5
educational materials to further advance communication and patient care. As an example of this—and with feedback from our ED—all newly hired ED nurse practitioners now spends time in our hand clinic learning proper splinting techniques as part of their orientation. Although it can be difficult to prove that inappropriate splints used over the short-term have a long-term deleterious effect, many patients were relieved when their large bulky splints were removed and replaced with smaller or alternative ones. Previous studies have found that inappropriate splinting may lead delayed recovery, a stiff hand, and possible permanent disability (5,6). In our study, these outcomes were not specifically tracked, but in 1 case of an inappropriate splint, a D4 soft tissue mallet finger was splinted with a single piece of 1-in aluminum from the distal palmar crease to the tip to the dorsum of the metacarpophalangeal joint. The mallet finger was not reduced and the metacarpophalangeal joint was painful. For this patient, the 2 weeks of inappropriate splinting added to the duration of subsequent treatment. Overall, we felt that improving the types of splints improved patient care and patient compliance with treatment. Compliance with splinting did improve in our study, but did not reach statistical significance. We sought to improve compliance in our educational intervention by promoting dorsal finger splints to allow for keyboard and phone usage, such that the use of a digit would be determined more by the injury than by the splint. We dissuaded excessive immobilization of uninjured digits or joints. We reinforced the positions of safety and demonstrated the use of appropriate splinting materials. All of these factors had been predicted by other authors to improve patients’ compliance with splinting, because many patients reported that large splints were cumbersome and interfered with activities (17). Limitations The first limitation in this study is the inability to determine the effect of each part of the multipronged educational intervention that we designed. Instead, the overall effectiveness of the intervention was measured via splint appropriateness as a final outcome. Separating the effects of the interventions may have been improved by giving a standardized knowledge test pre- and postlecture and having the participants self-grade on splinting confidence and performance before and after the one on one teaching sessions. A second limitation is that it is difficult to assess whether our original educational intervention explains the long-term effect or whether it is the continuing presence of posters and the collaborative relationship that has been fostered between the hand clinic and the ED. How-
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ever, the end result of improved splinting practice remains the same. A final limitation of this study is that we did not collect data on patient outcomes. The goal of this study was to initiate change in hand trauma management that we felt was deficient at our institution. By improving splinting practice, we would further hypothesize that there would be a decrease in the potential theoretical sequelae of delayed healing, hand stiffness, and slower return to work based on previous reports (4–6).
2. 3. 4. 5. 6.
CONCLUSIONS Hand injuries are exceptionally common, and the cornerstone of their initial management is the application of a splint. Inappropriate splinting may lead to excessive hand stiffness, loss of reduction, the need for additional therapy, increased requirement for surgery, and financial burden (18). A pre- and postprospective educational intervention study was successful at improving the quality of care of hand trauma as measured by splinting appropriateness at our institution. Our educational intervention was based on basic educational principles and may be applicable to improving standards of care at other institutions. In addition, the effect of our strategy lasted at 1 year of follow-up and may therefore lead to improved patient outcomes and less long-term personal, financial, and social costs to those suffering from hand trauma.
7. 8. 9.
10.
11. 12. 13. 14.
SUPPLEMENTARY DATA 15.
Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jemermed.2015.08.011.
16. 17.
REFERENCES 18. 1. Centers for Disease Control and Prevention website. The Centers for Disease Control and Prevention national hospital ambulatory medi-
cal care survey: 2010 emergency department summary tables. Available at: http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/ 2010_ed_web_tables.pdf. Accessed January 27, 2015. de Putter CE, Selles RW, Polinder S, et al. Economic impact of hand and wrist injuries: health-care costs and productivity costs in a population-based study. J Bone Joint Surg Am 2012;94:e56. Wilkins K, Mackenzie SG. Work injuries. Health Rep 2007;18: 25–42. Innis PC. Management of the stiff hand. In: Hunter JM, ed. Rehabilitation of the hand: surgery and therapy. 4th edn. Saint Louis, MO: Mosby; 1995:1129–39. Mackin EJ. Preventions of complications in hand surgery. Hand Clin 1986;2:429–47. Freiberg A. Management of proximal interphalangeal joint injuries. Can J Plast Surg 2007;15:199–203. Abraham MK, Sara S. The emergent evaluation and treatment of hand and wrist injuires. Emerg Med Clin North Am 2010;28:789– 809. Lifechez SD. Hand education for emergency residents: results of a pilot program. J Hand Surg Am 2012;37:1245–8. Scher DL, Boyer MI, Hammert WC, Wolf JM. Evaluation of knowledge of common hand surgery problems in internal medicine and emergency medicine residents. Orthopedics 2011;34: 279–81. Dickson JK, Morris G, Heron M. The importance of hand anatomy in the accident and emergency department: assessment of hand anatomy knowledge in doctors in training. J Hand Surg Eur Vol 2009;34:682–4. Kamarudin G, Penm J, Chaar B, Moles R. Educational interventions to improve prescribing competency: a systematic review. BMJ Open 2013;3:e003291. Le May S, Johnston CC, Choinie`re M, et al. Pain Management Practices in a Pediatric Emergency Room (PAMPER) study: interventions with nurses. Pediatr Emerg Care 2009;25:498–503. Berwick DM. Disseminating innovations in health care. JAMA 2003;289:1969–75. Baker R, Camosso-Stefinovic J, Gillies C, et al. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2010;3:CD005470. Grola R. Personal paper: beliefs and evidence in changing clinical practice. BMJ 1997;315:418. Brummel NE, Vasilevskis EE, Han JH, Boehm L, Pun BT, Ely EW. Implementing delirium screening in the intensive care unit: secrets to success. Crit Care Med 2013;41:2196–208. Sandford F, Barlow N, Lewis J. A study to examine patient adherence to wearing 24-hour forearm thermoplastic splints after tendon repairs. J Hand Ther 2008;21:44–52. Jaskolka JV, Andrews DM, Harold L. Occupational injuries reported in a Canadian university setting: a five-year retrospective study. Work 2009;34:273–83.
Splinting of Common Hand Injuries
ARTICLE SUMMARY 1. Why is this topic important? Hand trauma is among the most common presenting complaints to emergency departments. Splinting these injuries appropriately is the cornerstone of initial management of hand trauma. 2. What does this study attempt to show? We showed that current splinting practice was inadequate at our institution and that it could be improved with a targeted educational intervention. 3. What are the key findings? Our educational intervention improved splint appropriateness significantly from 49% to 69% (p = 0.04). Followup after 1 year found that splinting appropriateness remained high at 70% (p = 0.04). 4. How is patient care impacted? Appropriately splinted patients are less likely to suffer deleterious outcomes associated with inappropriate splinting, such as delayed healing, stiff hands, and a slower return to work.
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http://dx.doi.org/10.1016/j.jemermed.2015.08.011
Original Contributions
AN EDUCATIONAL INTERVENTION TO IMPROVE SPLINTING OF COMMON HAND INJURIES Giancarlo McEvenue, MD, Fiona FitzPatrick, RT (ORTHOPAED), and Herbert P. von Schroeder, MD, MSC, FRCSC University of Toronto Hand Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada Corresponding Address: Herbert P. von Schroeder, MD, MSC, FRCSC, Toronto Western Hospital, 399 Bathurst Street, East Wing 2nd Floor, Toronto, ON M5T 2S8, Canada
, Abstract—Background: Hand trauma is a top presenting complaint to hospital emergency departments (EDs) and can become costly if not treated effectively. The cornerstone for initial management of the traumatized hand is application of a splint. Improving splinting practice could potentially produce tangible benefits in terms of quality of care and costs to society. Objectives: We sought to determine the following: 1) whether the present standard of ED splinting was appropriate and 2) whether a strategically planned educational intervention could improve the existing care. Methods: We used a pre- and postprospective educational intervention study design. In the preintervention phase, patients referred to our hand clinic were assessed for injury and splint type. Splinting appropriateness was evaluated according to a predetermined hand surgeons’ expert consensus. Next, an educational intervention was targeted at all ED staff at our institution. Postintervention, all patients were again evaluated for splint appropriateness. A follow-up evaluation was performed at 1 year to see the long-term effects of the intervention. Results: The most common mechanism of injury of referred patients was falling (35%), and the most frequent injury was metacarpal fracture (40%). Splint appropriateness increased significantly postintervention from 49% to 69% (p = 0.048). At followup after 1 year, splinting appropriateness was 70% (p = 0.041). Conclusion: Appropriate hand splinting practice is essential for hand trauma management. Our results show that an educational intervention can successfully improve splinting practice. This quality of care initiative was low-
cost and demonstrated persistence at 1 year of followup. Ó 2015 Elsevier Inc. , Keywords—education; hand; intervention; splinting; trauma
INTRODUCTION Hand trauma is a common occurrence that accounted for nearly 3.7 million emergency department (ED) visits in the United States in 2008 (1). This injury burden carries with it a subsequent substantial cost in terms of lost work time, income, and disability (2,3). Hand trauma requires appropriate management to minimize issues, such as stiffness, contracture, and dysfunction (4–6). These types of injuries and issues pose a challenge for emergency and primary care physicians because of the complex anatomy and specialized treatment that the hand requires (7,8). Further complicating the matter is the fact that considerable gaps in hand anatomy knowledge exist among doctors working in EDs (9,10). Splinting the traumatized hand is the cornerstone of initial hand trauma management. At our hand clinic, it has been noted anecdotally that many splints applied in the ED are excessively large, involve uninjured parts of the hand, or are not in the optimal ‘‘position of safety’’ (Figure 1). Inappropriate splinting may lead to deleterious outcomes after injury, which may include delayed recovery, a stiff hand, and possibly permanent disability (5,6). As a quality of care improvement initiative we
Reprints are not available from the authors.
RECEIVED: 28 February 2015; FINAL SUBMISSION RECEIVED: 9 July 2015; ACCEPTED: 13 August 2015 1
2
G. McEvenue et al.
Figure 1. Examples of inappropriately splinted hand injuries. (A and B) Excessive splinting of a tuft fracture of the distal phalanx of the ring finger (B, white arrow). (C) A splint for a boxer’s fracture of the fifth metacarpal neck that did not immobilize the injury shown on the same patient’s radiograph (D, arrow).
proposed an educational intervention focused on appropriate splinting of hand trauma in the ED before referral. Educational interventions in health care settings have been shown by others to improve patient outcomes and level of care (11,12). It was our purpose to determine: 1) whether the present standard of ED splinting was appropriate and 2) if strategically planned educational initiatives could improve the existing care. METHODS The setting for this prospective study was a large urban tertiary care teaching hospital that has 2 EDs at separate
geographic sites. It is the normal practice of the institution that all hand injuries are referred to a single hand clinic for follow-up regardless of the magnitude or type of injury. Patients are typically seen in the hand clinic an average of 9 days after their ED visit (range, 1– 36 days). To establish clear guidelines on the appropriateness of splinting practice, 4 experienced fellowship-trained hand surgeons reached a consensus on appropriate splinting for common hand injuries. This included the type of splint, the range of materials, and the anatomic regions to be splinted based on the specific injury diagnoses. From this, a splinting reference chart (Figure 2) was created
Splinting of Common Hand Injuries
3
Figure 2. Splinting reference chart obtained via consensus from 4 fellowship-trained hand surgeons. Indications for splinting are listed in the left column; on the right are appropriate splint types, materials to be used, and a picture for clarity. DIP = distal interphalangeal joint, IP = interphalangeal joint, MCP = metacarpophalangeal joint, PIP = proximal interphalangeal jont, UCL = ulnar collateral ligament
with injury types and the corresponding appropriate splint. The chart included a list of injuries, a description of the preferred splint type, and photographs of representative splints. This chart was re-evaluated by the 4 hand surgeons for final consensus approval. Inappropriate splints were defined as those that positioned the hand incorrectly; unnecessarily immobilized uninjured areas of the extremity; were unnecessarily bulky/flimsy resulting in splint rotation, removal, or loss of reduction; splints that required excessive secondary reinforcement; splints that were too tight resulting in pressure issues or excessive distal swelling; and also injuries that should have been splinted but were not. Patient splint compliance was also recorded, as determined by splint removal or significant modification. A pilot study was conducted to estimate the sample size necessary to sufficiently power our study. A standardized data collection sheet was used to collect all pertinent demographic and splinting data. Pilot data collected over a 2-week period using the splint reference
chart and collection sheet revealed that 50% of patients referred to the Hand Clinic were splinted appropriately. On the basis of this, we designed our study to enroll 45 subjects, yielding 80% power to detect a difference of 25% between the groups before and after the educational intervention (a = 0.05, b = 0.2). The interventional difference was the difference between inappropriate and appropriate splints. The intervention itself was educational in nature and was directed at all those that manage hand trauma acutely at our center (i.e., 50 ED physicians, 2 nurse practitioners, and 6 resident physicians). The information was presented in the form of a lecture series, PowerPoint slides, and a poster outlining common hand injuries and the way to appropriately splint them (Supplementary material). All educational contact and initiatives were recorded for attendance and the date presented. The targets of the intervention were blinded to the purpose and methods of the study. Ethics approval was obtained from our institutional review board and informed consent was obtained from each
4
patient. No patients declined entry to the study. Phase I of the study was performed over a 3-month period in which data were prospectively collected on all adult ED patients referred to the hand clinic. Demographic data, ED diagnoses, and hand clinic diagnoses were recorded. We excluded patients who were <16 years of age, patients with whom we were not able to communicate because of language barriers, carpal or more proximal injuries, and injuries for which the hand service was directly involved during the initial ED management. A photograph of each ED splint was taken and then assessed for appropriateness based on the reference chart. Clinic staff who assessed splints were not directly involved in the study. We allowed for discretion in the decisionmaking of appropriateness for unusual or complicated injuries, but this was only applied on 2 occasions during the study (i.e., for soft tissue injuries where a dorsal splint may have been deleterious to tissue healing). We included patients with injuries that should have been splinted but were not. Phase II was the educational intervention. The intervention phase consisted of 2 PowerPoint lectures of problem-based hand trauma cases, and then one on one teaching sessions with the ED staff involved with hand splinting (i.e., ED doctors, emergency residents, and nurse practitioners). The lecture was provided by the senior author (board certified with added qualification in hand surgery) with live demonstrations of splinting techniques performed by a Registered Orthopaedic Technologist. In addition, 2 half-hour sessions on proper splinting technique were held with ED residents and nurse practitioners. Lecture slides were electronically distributed to all staff. Based on attendance taken at the lectures, we estimate that we were able to directly contact 92% of all the ED staff involved in the treatment of hand injuries. Afterward, we eliminated any barriers to proper splinting by ensuring that only approved splinting materials would be available in the referring EDs. All changes were confirmed before data collection. The last arm of our educational intervention consisted of pocket cards reinforcing the lecture and teaching session information by showing common hand injury diagnoses and recommended splinting techniques (similar to Figure 2). Two large posters (Supplementary material) were placed in each of the 2 EDs in the locations where splinting supplies were located to act as an additional reminder. Six weeks after these educational interventions, phase III data collection began using the same methods as phase I. Differences between groups before and after the educational intervention were analyzed with Prism software (version 6.01; GraphPad Software, La Jolla, CA) using a 2-tailed Fisher’s exact test. As a follow-up to determine the long-term effects of the intervention, data were collected again 1 year later.
G. McEvenue et al.
RESULTS Forty-nine patients were enrolled before the educational intervention and 54 were enrolled after the intervention. The demographic data were similar in both the pre- and postintervention groups (Table 1), with hand injuries occurring in mostly male patients who were in their late 30s. The 2 most common mechanisms of injury were falls on the hand (40% [41/103]) and strikes to the hand (28% [29/103]). Patients who were splinted and who underwent radiography in the ED were unchanged pre- and postintervention. Patient splint compliance, as determined by splint removal or significant modification, improved after intervention from 68% (30/44) to 74% (37/50), respectively, but this was not statistically significant. Diagnostic agreement between the ED and the hand clinic was obtained by comparing the ED referring diagnosis with the hand clinic final diagnosis. This was unchanged in the 2 groups at 78% (38/49) and 79% (43/54), respectively. Splint appropriateness, as determined from criteria based on a consensus of hand surgeon opinion, improved significantly from 49% (24/49) preintervention to 69% (37/ 54) after the educational initiatives (p = 0.048). A final data collection 1 year after the educational initiatives found that the splint appropriateness rate was 70% (35/ 50; p = 0.041).
Table 1. Patient Demographics, Injury, and Splint Appropriateness Pre- and Postintervention Preintervention Postintervention p value Patients (n) Mean age, yrs (SD) Sex Male Female Mechanism of injury, n (%) Crush Strike Fall Penetrating Twist Other Radiograph in ED Splinted in ED Splint compliance Diagnostic agreement Splint appropriateness After 1 year Final diagnosis Phalanx fracture Metacarpal fracture Tendon injury Ligament injury Other
49 36.1 (15.8)
54 39.8 (20.0)
30 (61%) 19 (39%)
34 (63%) 20 (37%)
6 (12%) 16 (33%) 13 (27%) 8 (16%) 2 (4%) 4 (8%) 45/49 (92%) 44/49 (90%) 30/44 (68%) 38/49 (78%) 24/49 (49%)
7 (11%) 13 (20%) 28 (43%) 7 (14%) 3 (5%) 5 (7%) 49/54 (91%) 50/54 (93%) 37/50 (74%) 43/54 (79%) 37/54 (69%) 35/50 (70%)
16 (33%) 20 (41%) 6 (12%) 5 (10%) 2 (4%)
16 (29%) 21 (38%) 6 (11%) 6 (11%) 6 (11%)
ED = Emergency department; SD = standard deviation. * Statistically significant (p < 0.05).
0.29 0.86
1 0.73 0.65 0.81 0.048* 0.041*
Splinting of Common Hand Injuries
DISCUSSION The dissemination of information and implementation of change are challenges that are being increasingly studied in health care (13,14). The success of implementation depends on the specific features of the change proposal, the target group, the setting, and the obstacles encountered to change. Educational interventions to implement quality improvement have been shown to work in the health care setting (11,12). The theory behind our intervention stems from adult learning theories and the intrinsic motivation of professionals to become better at what they do. The strategies this theory advocates are to develop local consensus, use small group interactive learning, and finally problembased learning to achieve the desired change in clinical practice (15). Our intervention was designed using all of these principles. We first developed consensus within our hand surgeon group and then attempted to develop interprofessional consensus across our institution on proper splinting of hand trauma. This collaborative approach was used to focus on the shared goal of better patient care, which is shared by all health care professionals. Our lecture series used a problem-based format on PowerPoint and one on one teaching sessions. Our approach was multifaceted to remove barriers to change and to learning, and to maximize exposure to our standardized splinting regime. To support our choice of educational intervention, a recent review of implementing delirium screening in the intensive care unit found that the most effective educational strategies were multifaceted training, such as lectures, case-based scenarios, one on one teaching, and interdisciplinary communication (16). The targeted area of quality improvement in this study was the technique of splinting for the initial management of hand trauma. Before the intervention, improper splinting rates were unacceptably high. Our intervention was effective by improving appropriate splints significantly from 49% to 69% (p = 0.048). We found almost immediate adoption of the preferred splinting methods because of our collaborative approach and focus on quality improvement. This rapid change may also have been related to the tenet of adult educational theory where change is believed to be driven by an internal striving for professional competence (15). The follow-up analysis of splint appropriateness demonstrated persistence at 70%. Although a decrease effect is possible over time and with changing staff (e.g., rotating residents and the addition of new ED physicians), the posters describing splinting techniques have remained a permanent fixture and have likely helped maintain a high rate of suitable splinting practices. The initiative may require updates, and additional updates have the benefit of being a conduit to introduce other
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educational materials to further advance communication and patient care. As an example of this—and with feedback from our ED—all newly hired ED nurse practitioners now spends time in our hand clinic learning proper splinting techniques as part of their orientation. Although it can be difficult to prove that inappropriate splints used over the short-term have a long-term deleterious effect, many patients were relieved when their large bulky splints were removed and replaced with smaller or alternative ones. Previous studies have found that inappropriate splinting may lead delayed recovery, a stiff hand, and possible permanent disability (5,6). In our study, these outcomes were not specifically tracked, but in 1 case of an inappropriate splint, a D4 soft tissue mallet finger was splinted with a single piece of 1-in aluminum from the distal palmar crease to the tip to the dorsum of the metacarpophalangeal joint. The mallet finger was not reduced and the metacarpophalangeal joint was painful. For this patient, the 2 weeks of inappropriate splinting added to the duration of subsequent treatment. Overall, we felt that improving the types of splints improved patient care and patient compliance with treatment. Compliance with splinting did improve in our study, but did not reach statistical significance. We sought to improve compliance in our educational intervention by promoting dorsal finger splints to allow for keyboard and phone usage, such that the use of a digit would be determined more by the injury than by the splint. We dissuaded excessive immobilization of uninjured digits or joints. We reinforced the positions of safety and demonstrated the use of appropriate splinting materials. All of these factors had been predicted by other authors to improve patients’ compliance with splinting, because many patients reported that large splints were cumbersome and interfered with activities (17). Limitations The first limitation in this study is the inability to determine the effect of each part of the multipronged educational intervention that we designed. Instead, the overall effectiveness of the intervention was measured via splint appropriateness as a final outcome. Separating the effects of the interventions may have been improved by giving a standardized knowledge test pre- and postlecture and having the participants self-grade on splinting confidence and performance before and after the one on one teaching sessions. A second limitation is that it is difficult to assess whether our original educational intervention explains the long-term effect or whether it is the continuing presence of posters and the collaborative relationship that has been fostered between the hand clinic and the ED. How-
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ever, the end result of improved splinting practice remains the same. A final limitation of this study is that we did not collect data on patient outcomes. The goal of this study was to initiate change in hand trauma management that we felt was deficient at our institution. By improving splinting practice, we would further hypothesize that there would be a decrease in the potential theoretical sequelae of delayed healing, hand stiffness, and slower return to work based on previous reports (4–6).
2. 3. 4. 5. 6.
CONCLUSIONS Hand injuries are exceptionally common, and the cornerstone of their initial management is the application of a splint. Inappropriate splinting may lead to excessive hand stiffness, loss of reduction, the need for additional therapy, increased requirement for surgery, and financial burden (18). A pre- and postprospective educational intervention study was successful at improving the quality of care of hand trauma as measured by splinting appropriateness at our institution. Our educational intervention was based on basic educational principles and may be applicable to improving standards of care at other institutions. In addition, the effect of our strategy lasted at 1 year of follow-up and may therefore lead to improved patient outcomes and less long-term personal, financial, and social costs to those suffering from hand trauma.
7. 8. 9.
10.
11. 12. 13. 14.
SUPPLEMENTARY DATA 15.
Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jemermed.2015.08.011.
16. 17.
REFERENCES 18. 1. Centers for Disease Control and Prevention website. The Centers for Disease Control and Prevention national hospital ambulatory medi-
cal care survey: 2010 emergency department summary tables. Available at: http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/ 2010_ed_web_tables.pdf. Accessed January 27, 2015. de Putter CE, Selles RW, Polinder S, et al. Economic impact of hand and wrist injuries: health-care costs and productivity costs in a population-based study. J Bone Joint Surg Am 2012;94:e56. Wilkins K, Mackenzie SG. Work injuries. Health Rep 2007;18: 25–42. Innis PC. Management of the stiff hand. In: Hunter JM, ed. Rehabilitation of the hand: surgery and therapy. 4th edn. Saint Louis, MO: Mosby; 1995:1129–39. Mackin EJ. Preventions of complications in hand surgery. Hand Clin 1986;2:429–47. Freiberg A. Management of proximal interphalangeal joint injuries. Can J Plast Surg 2007;15:199–203. Abraham MK, Sara S. The emergent evaluation and treatment of hand and wrist injuires. Emerg Med Clin North Am 2010;28:789– 809. Lifechez SD. Hand education for emergency residents: results of a pilot program. J Hand Surg Am 2012;37:1245–8. Scher DL, Boyer MI, Hammert WC, Wolf JM. Evaluation of knowledge of common hand surgery problems in internal medicine and emergency medicine residents. Orthopedics 2011;34: 279–81. Dickson JK, Morris G, Heron M. The importance of hand anatomy in the accident and emergency department: assessment of hand anatomy knowledge in doctors in training. J Hand Surg Eur Vol 2009;34:682–4. Kamarudin G, Penm J, Chaar B, Moles R. Educational interventions to improve prescribing competency: a systematic review. BMJ Open 2013;3:e003291. Le May S, Johnston CC, Choinie`re M, et al. Pain Management Practices in a Pediatric Emergency Room (PAMPER) study: interventions with nurses. Pediatr Emerg Care 2009;25:498–503. Berwick DM. Disseminating innovations in health care. JAMA 2003;289:1969–75. Baker R, Camosso-Stefinovic J, Gillies C, et al. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2010;3:CD005470. Grola R. Personal paper: beliefs and evidence in changing clinical practice. BMJ 1997;315:418. Brummel NE, Vasilevskis EE, Han JH, Boehm L, Pun BT, Ely EW. Implementing delirium screening in the intensive care unit: secrets to success. Crit Care Med 2013;41:2196–208. Sandford F, Barlow N, Lewis J. A study to examine patient adherence to wearing 24-hour forearm thermoplastic splints after tendon repairs. J Hand Ther 2008;21:44–52. Jaskolka JV, Andrews DM, Harold L. Occupational injuries reported in a Canadian university setting: a five-year retrospective study. Work 2009;34:273–83.
Splinting of Common Hand Injuries
ARTICLE SUMMARY 1. Why is this topic important? Hand trauma is among the most common presenting complaints to emergency departments. Splinting these injuries appropriately is the cornerstone of initial management of hand trauma. 2. What does this study attempt to show? We showed that current splinting practice was inadequate at our institution and that it could be improved with a targeted educational intervention. 3. What are the key findings? Our educational intervention improved splint appropriateness significantly from 49% to 69% (p = 0.04). Followup after 1 year found that splinting appropriateness remained high at 70% (p = 0.04). 4. How is patient care impacted? Appropriately splinted patients are less likely to suffer deleterious outcomes associated with inappropriate splinting, such as delayed healing, stiff hands, and a slower return to work.
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