[Ann Emerg Med. 2004;43:362-370.]
For a link to the full article please click the following: http://jasoncartermd.com/resources/pdf/19_Sterile%20vs%20Nonsterile%20gloves%20for%20uncomplicated%20lacerations.pdf
Vsevolod S. Perelman, MD, MSc, Gregory J. Francis, MD, BSc Tim Rutledge, MD, John Foote, MD, Frank Martino, MD, George Dranitsaris, MSc(Pharm)
Abstract Study objective: Although sterile technique for laceration management continues to be recommended, studies supporting this practice are lacking. Using clean non- sterile gloves rather than individually packaged sterile gloves for uncomplicated wound repair in the emergency department may result in cost and time savings. This study is designed to determine whether the rate of infection after repair of uncompli- cated lacerations in immunocompetent patients is comparable using clean nonsterile gloves versus sterile gloves. Methods: A prospective multicenter trial enrolled 816 individuals who were random- ized to have their wounds repaired by using sterile or clean nonsterile gloves. The attending physician or resident completed a checklist describing patient, wound, and management characteristics. The patients were provided with a questionnaire to be completed by the physician who removed their sutures at the prescribed time and indicated the presence or absence of infection. When follow-up forms were not returned, a telephone call was made to the patient to determine whether he or she had experienced any wound complications. Results: Follow-up was obtained for 98% of the sterile gloves group and 96.6% of the clean gloves group. There was no statistically significant difference in the inci- dence of infection between the 2 groups. The infection rate in the sterile gloves group was 6.1% (95% confidence interval [CI] 3.8% to 8.4%) and was 4.4% in the clean gloves group (95% CI 2.4% to 6.4%). The relative risk of infection was 1.37 (95% CI 0.75 to 2.52). Conclusion: This study demonstrated that there is no clinically important difference in infection rates between using clean nonsterile gloves and sterile gloves during the repair of uncomplicated traumatic lacerations. __________________________________________________ Questions: 1. True or False: Although published guidelines recommend sterile technique for laceration management, there is little evidence to support this method as standard of care. 2. Patients were excluded from this study for which of the following reasons: a. diabetes b. renal failure c. asplenia d. immunodeficiency e. all of the above were excluded from this study 3. Who was "blinded" in this study? a. the physician b. the nurse c. the EMT d. the patient e. the hospital administrator 4. True or False: The difference in infection rates between the "sterile glove" group and the "clean glove" group was not statistically significant. 5. Upon follow up phone call, who reported whether or not the wound was infected? a. the patient b. the patient's mother c. the patient's talking dog d. some random dude reached by wrong number Answers: 1. true 2. e 3. d 4. true 5. a |
ReplyDeleteThis month's Journal Club focuses on Wound Care.
The article was published in 2004...Oh, it seems like yesterday.
Prior to this article, I remember painstakingly caring for every wound with meticulous sterile technique. I would gracefully place betadine around each margin, trying not to get any inside the wound. Then I would carefully put on my sterile gloves trying not to bump anything. Sure enough, my phone would ring, I would answer it, and have to start all over again.
Some of us still use sterile gloves...I have to admit that I will often use them while repairing a wound. Old habits are hard to break. However, it is helpful to know that you can use "clean" gloves for most uncomplicated wounds and you do not necessarily need to open up a pack of sterile gloves if you'd prefer not. Instead, you can use those purple gloves from the box on the wall (assuming someone hasn't just sneezed on them) to repair most wounds.
In this study 816 patients were random-ized to have their wounds repaired by using sterile or clean nonsterile gloves.
Guess what...there was no data to suggest that infections are more common when lacerations are repaired with non- sterile gloves.
In statistical terms it is important to note that "no difference" is NOT the same as equal. The study would have required more patients (about 3000 in each group) to conclude that the two practices are statistically "equivalent."
It is also important to remember that patients were excluded if there was presence of diabetes mellitus, renal failure, asplenia, immunodeficiency, liver cirrhosis, tendency to form keloid scars, current use of antibiotics or need for prophylactic antibiotics as perceived by the treating physician (eg, artificial heart valves, bites, con- taminated wounds).
So, you may not want to do this in everyone, especially spleenless diabetic patients with dirty wounds, but it is probably ok to do it in most.
Thanks for reading.
5 Questions to follow Friday.
Your comments are welcomed
ReplyDeleteWK Shares:
ReplyDelete"I think the statistical discussion is confused a bit in the paper. I am not sure what "equivalency" is supposed to mean, but the study was powered to discover a robust difference and did not. Given the variability, the heterogenous patient mix and sites, I think that is pretty good.
What is not seen here is that the world of nosocomial infections is changing even over the past ten years. The number and types of multi-resistant bugs is increasing. Hand washing protocols and their monitors will not take note of the provider who, using non-sterile gloves, out of habit does more things in the environment with the gloves on than s/he would with sterile gloves on. Such as touch the leading edge of curtains in our E.D. that are rarely washed. Or parts of the room, the lips of Mayo tables or procedure carts that may not get wiped quite as thoroughly. Nor could such a paper take into account that ECC ANW is working in what is a relic physical facility, with walls, spaces and such almost assuredly out of date by modern I.D. hygiene standards for hospitals."
-WK
Emerg Med J. 2014 Feb;31(2):96-100. doi: 10.1136/emermed-2012-202143. Epub 2013 Jan 12.
ReplyDeleteTraumatic lacerations: what are the risks for infection and has the 'golden period' of laceration care disappeared?
Quinn JV1, Polevoi SK, Kohn MA.
Author information
Abstract
OBJECTIVE:
To determine risk factors associated with infection and traumatic lacerations and to see if a relationship exists between infection and time to wound closure after injury.
METHODS:
Consecutive patients presenting with traumatic lacerations at three diverse emergency departments were prospectively enrolled and 27 variables were collected at the time of treatment. Patients were followed for 30 days to determine the development of a wound infection and desire for scar revision.
RESULTS:
2663 patients completed follow-up and 69 (2.6%, 95% CI 2.0% to 3.3%) developed infection. Infected wounds were more likely to receive a worse cosmetic rating and more likely to be considered for scar revision (RR 2.6, 95% CI 1.7 to 3.9). People with diabetes (RR 2.70, 95% CI 1.1 to 6.5), lower extremity lacerations (RR 4.1, 95% CI 2.5 to 6.8), contaminated lacerations (RR 2.0, 95% CI 1.2 to 3.4) and lacerations greater than 5 cm (RR 2.9, 95% CI 1.6 to 5.2) were more likely to develop an infection. There were no differences in the infection rates for lacerations closed before 3% (95% CI 2.3% to 3.8%) or after 1.2% (95% CI 0.03% to 6.4%) 12 h.
CONCLUSIONS:
Diabetes, wound contamination, length greater than 5 cm and location on the lower extremity are important risk factors for wound infection. Time from injury to wound closure is not as important as previously thought. Improvements in irrigation and decontamination over the past 30 years may have led to this change in outcome.
KEYWORDS:
Wounds, Wounds, Research, Wounds, Treatment