Establishing a written advice sheet to patients consulting for wound to emergency ward improves postemergency care
1Department of Emergency, Université de Paris, PARCC, INSERM, AP-HP, Georges Pompidou European Hospital, F-75015 Paris, France
2Department of Emergency, AP-HP, Georges Pompidou European Hospital, F-75015 Paris, France
3Department of Emergency, Paris University, AP-HP, Georges Pompidou European Hospital, F-75015 Paris, France
Keywords: Emergency department, follow-up compliance, wound
OBJECTIVES: Sutures require follow-up visits for favorable evolution. To improve postemergency wound care, we decided to include a standardized advice sheet for patients based on current recommendations. The objective is to assess its effectiveness on outpatients' compliance after being discharged from the emergency department (ED).
METHODS: We performed a prospective, pre–post design trial in an ED of a teaching hospital. We included for two consecutive months all patients aged ≥16 years old and consulting for wounds that needed suturing, and we excluded chronic wounds, burns, and hand wounds since they all need special care. During the 1st month, all patients received during ED visit usual verbal instructions concerning the postemergency care (Group A). During the 2nd month, all patients received usual verbal instructions and a standardized written advice sheet that detailed postemergency wound care (Group B). We organized telephone follow-up after the suture removal date and asked about dressing changes, appearance of infection signs, and respect of suture removal date. We compared patients;' characteristics in the two groups and performed a multivariable logistic regression using compliance to discharge instructions as our endpoint.
RESULTS: For 2 months, 509 patients consulted for wounds. 119 (23.4%) patients were included in the study and followed. Baseline characteristics of patients did not differ between the two groups. Patients who received the advice sheet (Group B) had a better compliance in postemergency care (91.7% vs. 72.9%;P= 0.01). Moreover, there were significantly less dressing changes in Group B than in Group A (5.3 [2.2] vs. 12.9 [7.7];P< 0.01) and suture removal date was more in agreement with recommendations in Group B (83.9% vs. 66.7%;P= 0.03). Occurrence of infection was not significantly different between groups (9.7% vs. 13.7%;P= 0.37).
CONCLUSION: For the management of wound care, discharge hospital process including a written advice sheet improves outpatients' compliance and postemergency care.
Wounds and lacerations represent up to 13% of the consultations to the emergency department (ED)., During emergency management, patients receive discharge instructions from their doctors concerning wound care and signs of complications. Usually, little time is allocated to providing discharge instructions and demonstrations of wound care. Therefore, patients might not be clear about the discharge instructions and thus are at risk for not following wound care and for additional complications such as infection, dehiscence, or bad cosmetic results.,,
There is a wide variety of hospital discharge organization process (verbal or written instructions, follow-up calls, or smartphone applications), but there is currently no formal process for assessing patients' compliance.
To improve patients' compliance to wound care, we implemented an advice sheet based on consensus conference recommendations and gave it to injured patients. Our goal was to compare follow-up compliance for ED patients with two different discharge organization processes. We also evaluated several patients and wound characteristics as possible factors affecting greater outpatient follow-up compliance.
Material and Methods
Study design setting, and selection of participants
AP-HP Research Ethics Review Committee approved the investigation with waiver of informed consent (IRB00011591, 10 January 2019). This study was a prospective clinical trial at an ED in a teaching hospital. During two consecutive months, we included all patients aged sixteen years and over consulting for a wound that needed suturing. Exclusion criteria were chronic wounds, burns, and hand wounds. During the 1st month, all patients were given usual verbal discharge instructions by the health professionals regarding the postemergency care (Group A). During the 2nd month, in addition to usual verbal discharge instructions, all included patients were given a written advice sheet [Appendix 1]. Patients from this second period composed the Group B. All patients were called on the phone after the suture removal date and asked about the respect of discharge written instructions from the advice sheet: dressing changes, appearance of infection signs, and respect of suture removal date [Appendix 2].
Sample size calculation
Assuming an adherence rate of 70% with only verbal discharge instructions and 90% with the advice sheet, it is necessary to include 118 patients for a power of 80% and a one-sided significance level of 5%.
During the ED visit, we recorded data about wound characteristics including location, size, time delay from injury to ED visit, signs of infection (inflammatory signs and secretion), suture technique used (simple stitches or staples), and number of sutures. We also recorded patient characteristics (age and sex) and circumstance of incident (workplace or domestic incident). After ED discharge, each patient that had been sutured was called 1 or 2 days after the recommended removal date. To ascertain if patients followed up discharge instruction, we established for both groups a single standardized questionnaire based on the Bates–Jensen Wound Assessment Tool. The assessment of compliance for following instructions was based on patient self-reports, changing dressing counts, and rates of prescription refills [Appendix 2]. Patients were asked about number of dressing changes, appearance of infection signs, use of antiseptic, adherence to discharge instruction, and suture removal date. The data were collected by the first (R.C.) and the second authors (T.T.).
Our main outcome was proportion of compliant patients in each group. Compliance was defined as acting according to emergency health professional's recommendation. Compliance with wound healing was determined by the telephone interview. Patients were asked, “On discharge, were any medications advised for you?” and “Were you able to fill these prescriptions after your ED visit?” Patients were defined as noncompliant with prescription filling if they answered affirmatively to the former question and negatively to the latter.
Measurements Written advice sheet
Written advice sheet is based on evidence-based recommendations.,, The aim of the written advice sheet is to inform patients about how to manage their wound and to limit complications. The written advice sheet is composed of 3 parts: suture removal date according to wound location, procedural steps of the wound care, and listing of signs of complications. The procedural steps of wound care included dressing application instructions, dressing change frequency, discarding of supplies, and aseptic procedure. To minimize the number of documents at the ED discharge, the written advice sheet is included at the end of the physician's prescription for medication.
Continuous data were expressed as mean ± standard deviation (SD). Categorical data were expressed as frequencies and percentages. In the case of absence of linearity, continuous variables were dichotomized according to the median. Comparisons used the Chi-square test for categorical variables and Student's t-test or Mann–Whitney–Wilcoxon test, when appropriate, for continuous variables. Patients were compared according to their group (A or B). The primary endpoint was follow-up compliance and the secondary was the incidence of reported infections based on patient symptomatology. We performed a multivariable logistic regression to evaluate the association between follow-up compliance, group, and prognostic factors.
All analyses were two-sided and a P value below 0.05 was considered to be statistically significant. Statistical analysis was performed using R studio software (R Development Core Team (2019), Vienna, Austria).
During the study, 509 patients visited the ED for traumatic laceration. Of these, 271/509 (53.2%) patients had a hand laceration, 3/509 (0.006%) had a bite injury, 17/509 (0.03%) had burns, 7/509 (0.01%) presented a delay injury/trauma to ED visit too long (>6 h) to allow suturing, 35/509 (0.07%) received tissue adhesive, and 21/509 (0.04%) were treated with simple gauze dressing and thus were not included in the analysis. During the follow-up period, 31/509 (0.06%) were lost (not answering to telephone calls or wrong telephone number). Finally, n = 119/509 (23.2%) were followed up and included in the analysis: 59 out of 119 (49.6%) during the period A and 60 out of 119 (50.4%) in the period B [Figure 1]. The mean age (SD) was 50.7 (±23.9), and 70/119 (58.8%) were male. Wounds were distributed on the face (n = 84 [70.6%]), upper limb (n = 18 [15.1%]), lower limb (n = 15 [12.6%]), and trunk (n = 2 [0.02%]).
At the ED presentation, there was no significant difference between the Group A and B in terms of delay from injury to wound closure, wound size, numbers of sutures, cleaned and contained wound, the use of antiseptic, injury site, time recommended to sutures&' removal, wound length, and environmental context (workplace and domestic accidents). Overall, the adherence rate to discharge instructions was 82.4% (98/119) [Table 1].
During the postemergency care period after discharge from ED, there was no significant difference (P > 0.05) between the Group A and the Group B, in terms of antiseptic use or standard soap with water, wound complications occurrence such as infection, minor dehiscence or erythema, duration of work stoppage, and short-term unscheduled return rate. The Group B had significantly higher adherence to wound care instructions (91.7 vs. 72.9%,P= 0.02) and a higher mean number of dressing changes (5.45 vs. 12.9,P= 0.001), and their suture removal date was more in agreement with recommendations (83.9% [n = 52] vs. 66.7% [n = 40];P= 0.03) [Table 1]. Occurrence of infection was not significantly different between Group B and A (9.7% [n = 6] vs. 13.7% [n = 8];P= 0.37). We did not observe a significant difference regarding clinical and wound characteristics between compliant and noncompliant patients [Table 2].
After adjusting on patients and wound cofounders (age, gender, wound size, adequation to suture removal date, and the use of standard soap with water), the hospital discharge process using an additional written advice sheet (Group B) is significantly associated with follow-up compliance (adjusted odds ratio: 4.25 [1.22–18.2]) [Table 3].
In this study, we observed a significant relationship between the hospital discharge process that included verbal instructions and written advice sheet and patients' compliance for wound care. Even after adjustment for patients' and wounds' characteristics, the use of additional advice sheet is associated with higher follow-up compliance.
Prio studies and literature reviews showed that patients can encounter different problems in the 1st weeks after they have been discharged from ED, such as emotional problems (uncertainty and anxiety).,,,, For instance, Bull explained that patients were given few discharge instructions regarding medication and their condition, and they might experience difficulties with recognizing the signs of complications, managing medications, diet and other aspects of treatment and thus may be at higher risk for complications. Our study showed that an additional advice sheet improved outpatient compliance. The most probable interpretation of this result is that advice sheet allowed clearer explanation to ED patients about managing wound care after stitches or staples. Patients' discharge instructions are easy to apply. Therefore, they felt confident in following the discharge instructions. Other studies showed similar findings. Thomas et al. and Magnusson et al. compared the effect of providing ED patients with outpatient appointments and outpatient follow-up compliance. They found that patients who received detailed instructions (date of appointment and wound care instructions) at the time of ED discharge were significantly more likely to comply with follow-up instructions. Both of these prior studies were consistent with our findings that organizing outpatient care from the ED significantly improves compliance.
Many studies,,,, have investigated the use of telephone follow-up (TFU) to improve outpatient compliance. In our study, this factor has been considered and controlled. Patients that just received verbal discharge instructions (Group A) and those that received additional advice sheet (Group B) have been called at the date of suture removal. The high rate in both Group A and B might be attributable to the use of TFU. However, in a systematic review, Mistiaen and Poot investigated the effect of TFU in reducing postdischarge problems. They observed that TFU did not influence the outpatient compliance.
Patients' understanding of their conditions and treatments is strongly related to adherence. Studies have demonstrated that patients who understand the principle of the prescription are twice as likely to fill it than those who do not understand the principles. Outpatients' adherence and understanding are associated with the amount and type of information given by health professionals. In our study, we did not evaluate in each group the time needed to give and explain discharge instructions to the patient. This time is probably longer for a patient that received both verbal and written discharge instructions (Group B). Therefore, the time factor might be an essential part of greater adhering to discharge instructions in the Group B.
Discharge instructions must be clear to be understood and applied by the patient. Nowadays, recommendations are not very precise concerning wounds' care after discharge from the ED., In our study, the advice sheet was based on actual recommendations (French Emergency Medicine Society, 2018). This could explain the absence of any difference regarding dressing application, dressing change frequency, discarding of supplies, and aseptic procedure between the two groups. This recommendation was recently updated and did not change concerning wound care.
Due to its nonrandomized study, it precludes any causal relationship between hospital discharge process (advice sheet) and outpatients compliance. Despite efforts to control confounders using different analytical strategies, some potential biases may have been disregarded. For example, the use of TFU might induce measurement bias and recall bias. However, TFU has been performed few days after being discharged from ED in order to minimize these types of bias. The design of our study can also be source of limitations. Pre–post studies do not have control over other elements that are also changing at the same time as the intervention is implemented. Therefore, changes in outpatients' compliance during the study period cannot be fully attributed to the advice sheet.
In the management of wound, discharge hospital process provided by health professionals that included verbal instructions and advice sheet improves significantly the patients' compliance to wound care. To ensure patients' compliance, discharge instructions should be short, simple, and clear.
How to cite this article: Chocron R, Tamisier T, Feral-Pierssens AL, Juvin P. Establishing a written advice sheet to patients consulting for wound to emergency ward improves postemergency care. Turk J Emerg Med 2021;21:6-13
Presentation(s) or awards at a meeting: The results have been presented at the French Emergency Medicine Society Congress (Paris) and at the European Society for Emergency Medicine (Glasgow) in 2018.
AP-HP Research Ethics Review Committee approved the investigation and with waiver of informed consent (IRB00011591, 10 January 2019).
R.C. and T.T. conceived and designed the experiments; R.C. and T.T. performed the experiments; R.C. analyzed and interpreted the data; R.C. and T.T contributed reagents, materials, analysis tools or data, R.C., T.T., A-L.F-P, and P.J. wrote the paper and review the article.
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